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

  • Jason A. Wallis
    Correspondence
    Address correspondence and reprint requests to: Jason A. Wallis, Physiotherapy Department, Eastern Health, Angliss Hospital, Albert Street, Upper Ferntree Gully, Victoria 3156, Australia. Tel: 61-3-9764-6150; Fax: 61-3-9764-6149.
    Affiliations
    Physiotherapy Department, Eastern Health, Melbourne, Victoria, Australia
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  • Nicholas F. Taylor
    Affiliations
    Allied Health Clinical Research Office, Eastern Health, Australia

    Musculoskeletal Research Centre, La Trobe University, Australia

    School of Physiotherapy, La Trobe University, Australia
    Search for articles by this author
Open ArchivePublished:October 17, 2011DOI:https://doi.org/10.1016/j.joca.2011.09.001

      Summary

      Objective

      To determine if pre-operative interventions for hip and knee osteoarthritis provide benefit before and after joint replacement.

      Method

      Systematic review with meta-analysis of randomised controlled trials (RCTs) of pre-operative interventions for people with hip or knee osteoarthritis awaiting joint replacement surgery.
      Standardised mean differences (SMD) were calculated for pain, musculoskeletal impairment, activity limitation, quality of life, and health service utilisation (length of stay and discharge destination). The GRADE approach was used to determine the quality of the evidence.

      Results

      Twenty-three RCTs involving 1461 participants awaiting hip or knee replacement surgery were identified. Meta-analysis provided moderate quality evidence that pre-operative exercise interventions for knee osteoarthritis reduced pain prior to knee replacement surgery (SMD (95% CI)=0.43 [0.13, 0.73]). None of the other meta-analyses investigating pre-operative interventions for knee osteoarthritis demonstrated any effect. Meta-analyses provided low to moderate quality evidence that exercise interventions for hip osteoarthritis reduced pain (SMD (95% CI)=0.52 [0.04, 1.01]) and improved activity (SMD (95% CI)=0.47 [0.11, 0.83]) prior to hip replacement surgery. Meta-analyses provided low quality evidence that exercise with education programs improved activity after hip replacement with reduced time to reach functional milestones during hospital stay (e.g., SMD (95% CI)=0.50 [0.10, 0.90] for first day walking).

      Conclusion

      Low to moderate evidence from mostly small RCTs demonstrated that pre-operative interventions, particularly exercise, reduce pain for patients with hip and knee osteoarthritis prior to joint replacement, and exercise with education programs may improve activity after hip replacement.

      Keywords

      Introduction

      Hip and knee joint replacement surgery is a cost effective intervention for people with severe osteoarthritis who are unresponsive to conservative therapy
      • Losina E.
      • Walensky R.P.
      • Kessler C.L.
      • Emrani P.S.
      • Reichmann W.M.
      • Wright E.A.
      • et al.
      Cost effectiveness of total knee arthroplasty in the United States patient risk and hospital volume.
      • Chang R.W.
      • Pellisier J.M.
      • Hazen G.B.
      A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip.
      . Patients often have to wait many months for their surgery
      • Hoogeboom T.J.
      • van den Ende C.H.M.
      • van der Sluis G.
      • Elings J.
      • Dronkers J.J.
      • Aiken A.B.
      • et al.
      The impact of waiting for total joint replacement on pain and functional status: a systematic review.
      • Osborne R.
      • Haynes K.
      • Jones C.
      • Chubb P.
      • Robbins D.
      • Graves S.
      Orthopaedic Waiting List Project Summary Report Victorian Government.
      • Australian Institute of Health and Welfare (AIHW)
      Australian Hospital Statistics 2003–04. AIHW Cat. No. HSE 37.
      North East Local Health Integration Network: Integrated Health Service Plan.
      and during that time endure severe and unremitting pain that restricts their activity in daily tasks and participation in their normal societal roles
      • Fielden J.M.
      • Cumming J.M.
      • Horne J.G.
      • Devane P.A.
      • Slack A.
      • Gallagher L.M.
      Waiting for hip arthroplasty: economic costs and outcomes.
      . Pre-operative interventions such as exercise and education for patients awaiting hip and knee replacement surgery are performed in the expectation that these programs may improve pre-operative outcomes as well as improving recovery post-surgery.
      Recent systematic reviews with meta-analyses have demonstrated that land-based exercise is effective for reducing pain and improving function in people with knee osteoarthritis and reducing pain in people with hip osteoarthritis
      • Fransen M.
      • McConnell S.
      Land-based exercise for osteoarthritis of the knee: a meta-analysis of randomised controlled trials.
      • Fransen M.
      • McConnell S.
      • Hernandez-Molina G.
      • Reichenbach S.
      Exercise for osteoarthritis of the hip.
      . These positive results suggest that interventions that optimise pain and function for people with osteoarthritis could also enhance health outcomes for people with osteoarthritis who are also awaiting joint replacement surgery. A previous review
      • Ackerman I.N.
      • Bennell K.L.
      Does pre-operative physiotherapy improve outcomes from lower limb replacement surgery? A systematic review.
      investigated pre-operative physiotherapy for patients undergoing hip and knee replacement. They found no clinically important differences following knee replacement and no conclusive findings following hip replacement. Another review
      • McDonald S.
      • Hetrick S.E.
      • Green S.
      Pre-operative education for hip or knee replacement.
      of randomised controlled trials (RCTs) delivering pre-operative education found no post-operative benefit but some evidence of reduced pre-operative anxiety. These two reviews were single discipline interventions and did not consider multidisciplinary and mixed interventions including group programs. Another 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.
      investigated both single and multidisciplinary interventions finding evidence that multidisciplinary interventions such as physiotherapy or occupational therapy combined with education effective particularly for the most fragile patients. However several trials have been completed since the literature search of the 2007 publication
      • 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.
      .
      Therefore the aim of this review is to determine the effect of pre-operative non-pharmacological and non-surgical interventions before and after joint replacement for patients with knee or hip osteoarthritis awaiting lower limb joint replacement surgery on pain, musculoskeletal impairment, activity, quality of life, and health service utilisation.

      Method

       Search strategy

      The electronic databases MEDLINE, PUBMED, CINAHL and EMBASE were searched until August 2010. The three concepts of population, intervention and design were combined with the ‘AND’ operator. Population was defined as participants with osteoarthritis of the hip or knee on a waiting list for lower limb joint replacement surgery. Intervention was defined as a non-surgical or non-pharmacological intervention for osteoarthritis. The design was a RCT to achieve the most valid information about the effectiveness of the interventions. For each concept synonyms and MeSH terms were combined with the ‘OR’ operator (Appendix).
      All articles were imported to bibliographic software. Two reviewers independently screened the articles by title and abstract utilising pre determined eligibility criteria. Any disagreements were resolved by discussion. Full text copies of articles that were not definitely excluded on title and abstract were retrieved and the criteria were reapplied. Uncertain cases were discussed by the reviewers to achieve consensus. Database searching was supplemented by hand searching the reference lists of included articles and the application of citation tracking using Google scholar.

       Eligibility criteria

      The studies were eligible if (1) at least 80% of the participants had hip or knee osteoarthritis; (2) participants were wait-listed for lower limb joint replacement surgery; (3) the intervention was non-surgical and non-pharmacological (Table I); (4) a RCT design was used; (5) written in English.
      Table INon-surgical and non-pharmacological interventions eligible for inclusion
      Intervention(s)Examples
      Pre-operative Rehabilitation ProgramsCombined interventions including exercise and education
      PhysiotherapyExercise therapy, manual therapy, hydrotherapy, taping, electrotherapy
      Psychology, counsellingCognitive therapy, behavioural therapy
      DieteticWeight reduction programs
      OrthotistBraces
      PodiatryOrthotics
      Occupational therapyHome visits
      OtherAcupuncture, dry needling, Tai Chi, Ai Chi
      The studies were ineligible if the intervention was (1) single session only such as an education booklet or advice; (2) commenced within 1 week of surgery.

       Data collection process

      Pre-designed spreadsheets were used to extract data on participants, interventions, outcomes measures and results. Data were also collected on adverse events, recruitment and adherence to the interventions.

       Risk of bias in individual studies

      Two researchers independently applied a validated scale (PEDro) to rate the methodological quality of all the trials
      • de Morton N.A.
      The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study.
      . The eleven items are based upon the Delphi list
      • Verhagen A.P.
      • de Vet H.C.
      • de Bie R.A.
      • Kessels A.G.
      • Boers M.
      • Bouter L.M.
      • et al.
      The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus.
      . Each item is scored ‘yes’ or ‘no’ with a maximum score of 10 as criterion one is not scored. The PEDro score has demonstrated moderate inter-rater reliability [ICC=0.68 (95% CI 0.57, 0.76)] for clinical trials
      • Maher C.G.
      • Sherrington C.
      • Herbert R.D.
      • Moseley A.M.
      Reliability of the PEDro scale for rating quality of randomised controlled trials.
      . A trial with a score of 6 or more was considered to be high quality consistent with previous reviews
      • Hahne A.J.
      • Ford J.J.
      • McMeeken J.
      Conservative management of lumbar disc herniation with associated radiculopathy.
      • Maher C.G.
      A systematic review of workplace interventions to prevent low back pain.
      .

       Synthesis of results

      Standardised mean differences (SMD) (effect sizes) and 95% confidence intervals were calculated from post-intervention means and standard deviations

      Centre for Evaluation and Monitoring, Durham University. Effect Size Calculator. http://www.cemcentre.org/evidence-based-education/effect-size-calculator.

      . Where the standard error or 95% confidence interval was provided this was converted to standard deviations. Secondly the P-value was used for estimating standard deviation. Thirdly standard deviation was estimated from range
      • Hozo S.
      • Djulbegovic B.
      • Hozo I.
      Estimating the mean and variance from the median, the range and the size of the sample.
      or if none of these was available it was imputed from graph.
      Positive SMD values were used to indicate that the outcome favoured the intervention group. Values of <0.2 indicated a small effect size, 0.2–0.5 a moderate effect size and >0.8 a larger effect size
      • Cohen J.
      Statistical Power Analysis for the Behavioural Sciences.
      .
      Meta-analysis was performed using inverse variance method and random effects analysis
      • Review Manager (RevMan)
      [Computer Program] Version 5.0.
      . Combining data in a meta-analysis was planned where a minimum of two trials were clinically homogeneous. A trial was considered clinically homogenous if a common population, intervention and outcome measure was used. If combining data were not considered reasonable due to clinical heterogeneity the reporting of the results was provided in a table and descriptive format.
      The GRADE approach
      • GRADE Working Group
      Grading quality of evidence and strength of recommendations.
      was applied to each meta-analysis performed to determine the quality of evidence. This approach entailed downgrading the evidence from high to moderate to low and to very low quality based on criteria. Downgrading the evidence one place (e.g., high to moderate quality) would occur if: (1) the PEDro score was <6 for the majority of trials in the meta-analysis, (2) there was greater than low levels of statistical heterogeneity between the trials (I225%)
      • Higgins J.P.T.
      • Thompson S.G.
      • Deeks J.J.
      • Altman D.G.
      Measuring inconsistency in meta-analysis.
      and (3) there were large confidence intervals indicating a small number of participants. If there were serious issues with the methodological quality, such as all trials in the meta-analysis were <6 PEDro score without allocation concealment and blinded assessors, then a double downgrade would occur (e.g., from high to low quality). A footnote was used to explain the reasons for the grade applied to each meta-analysis.

      Results

       Study selection

      The combined database search yielded 2274 trials (inclusive of duplicates). Forty-one trials were retrieved for full text review and a total of 24 trials fulfilled inclusion criteria. Two trials
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      provided data about the same trial. Therefore, in this review these two articles were considered one trial resulting in a final yield of 23 trials (Fig. 1).
      Figure thumbnail gr1
      Fig. 1
      • Bolus S.A.
      • Katx J.N.
      • Parker R.A.
      • Bierbaum B.E.
      • Connolly C.E.
      • Iverson M.D.
      • et al.
      The effects of preoperative exercise on functional status in persons undergoing total hip arthroplasty.
      ,
      • Butler G.S.
      • Hurley C.M.
      • Buchanan K.L.
      • Smith-Vanhorne J.
      Prehospital education: effectiveness with total hip replacement surgery patients.
      ,
      • Crowe J.
      • Henderson J.
      Pre-arthroplasty rehabilitation is effective in reducing hospital stay.
      ,
      • Daltroy L.H.
      • Morlino C.
      • Holley M.
      • Eaton R.N.
      • Poss R.
      • Liang M.H.
      Preoperative education for total hip and knee replacement patients.
      ,
      • Foster N.
      The value of acupuncture or exercise-based physiotherapy for patients waiting for knee replacement surgery.
      ,
      • Giraudet J.
      • Coste J.
      • Vastel L.
      • Pacault V.
      • Jeanne L.
      • Lamas J.P.
      • et al.
      Positive effect of patient education for hip surgery. A randomised trial.
      ,
      • Gursen M.D.
      • Ahrens J.
      Research. The key to a new home protocol: prospective visits.
      ,
      • Larsen K.
      • Hvass K.E.
      • Hansen T.B.
      • Thomsen P.B.
      • Soballe K.
      ,
      • Mancuso C.A.
      • Graziano S.
      • Briskie L.M.
      • Peterson M.G.
      • Pellicci P.M.
      • Salvati E.A.
      • et al.
      Randomized trials to modify patients’ preoperative expectations of hip and knee arthroplasties.
      ,
      • Martini F.
      • Horstmann T.
      • Knak J.
      • Mayer F.
      • Zacher J.
      The importance of preoperative physiotherapy before total hip replacement in osteoarthritis of the hip joint.
      ,
      • Peterson M.K.
      • Madsen C.
      • Anderson N.T.
      • Soballe K.
      Efficacy of multimodal optimization of mobilization and nutrition in patients undergoing hip replacement a randomized clinical trial.
      ,
      • Radenas-Martinez S.
      • Santos-Andres J.F.
      • Abril-Boren C.
      • Usabiaga-Bernal T.
      • Abouh-Lais
      • Aguilar-Naranjo J.J.
      Effectiveness of a pre-surgery rehabilitation program in total knee arthroplasty.
      ,
      • Rivard A.
      • Warren S.
      • Voaklander D.
      • Jones A.
      The efficacy of preoperative home visits for total hip replacement clients.
      ,
      • Rodgers J.A.
      • Garvin K.L.
      • Walker C.W.
      • Morford D.
      • Urban J.
      • Bedard J.
      Preoperative physical therapy in primary total knee arthroplasty.
      ,
      • Sandell C.
      A multidisciplinary assessment and intervention for patients awaiting total hip replacement to improve their quality of life.
      ,
      • Soni A.
      • Mudge N.
      • Joshi A.
      • Wyatt M.
      • Williamson L.
      Severe knee osteoarthritis: a study of combined acupuncture and physiotherapy versus home exercise advice in patients awaiting total knee arthroplasty.
      ,
      • Spalding N.J.
      A comparative study of the effectiveness of a preoperative education programme for total hip replacement patients.
      ,
      • Tillu A.
      • Tillu S.
      • Vowler S.
      Effect of acupuncture on knee function in advanced osteoarthritis of the knee: a prospective, non-randomised controlled study.
      selection process.

       Study characteristics

       Participants

      From 23 RCTs involving 1461 participants, 922 were awaiting knee replacement, 305 awaiting hip replacement and 234 awaiting either hip or knee replacement. The mean age of participants was 67.2 years and 66% were women. From available data the average body mass index was 30.2 kg/m2, the mean number of days on the waiting list was 81 days and mean duration of osteoarthritis symptoms was 6.7 years.

       Interventions

      Nineteen trials
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      • 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.
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.C.
      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.
      • Berge D.J.
      • Dolin S.J.
      • Williams A.C.
      • Harman H.
      Pre-operative and post-operative effect of a pain management programme prior to total hip replacement: a randomized controlled trial.
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term study.
      • Crotty M.
      • Prendergast J.
      • Battersby M.W.
      • Rowett D.
      • Graves S.E.
      • Leach G.
      • et al.
      Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised 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.
      • 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.
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip 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.
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • Mscule F.
      • Quinto L.
      • Hernandez M.V.
      • 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.
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • 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.
      • Walls R.J.
      • McHugh G.
      • O’Gorman D.J.
      • Moyna N.N.M.
      • O’Byrne J.M.
      Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty. A pilot 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.
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      • 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.
      compared pre-operative interventions with standard care while four trials
      • 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.
      • Haslam R.
      A comparison of acupuncture with advice and exercises on the symptomatic treatment of osteoarthritis of the hip – a randomised controlled trial.
      • Mitchell C.
      • Walker J.
      • Walters S.
      • Morgan A.B.
      • Binns T.
      • Mathers N.
      Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial.
      • Tillu A.
      • Roberts C.
      • Tillu S.
      Unilateral versus bilateral acupuncture on knee function in advanced osteoarthritis of the knee – a prospective randomised trial.
      compared interventions.
      For participants awaiting knee joint replacement, 12 trials
      • 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.
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.C.
      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.
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term study.
      • Crotty M.
      • Prendergast J.
      • Battersby M.W.
      • Rowett D.
      • Graves S.E.
      • Leach G.
      • et al.
      Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised 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.
      • 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.
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • Mscule F.
      • Quinto L.
      • Hernandez M.V.
      • 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.
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • 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.
      • Walls R.J.
      • McHugh G.
      • O’Gorman D.J.
      • Moyna N.N.M.
      • O’Byrne J.M.
      Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty. A pilot study.
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      • 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.
      investigated pre-operative interventions vs standard care. Exercise programs provided by a physiotherapist or other therapist were the most common intervention in seven trials
      • 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.
      • 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.
      • 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.
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • 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.
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      • 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.
      for knee osteoarthritis. Other interventions included exercise combined with educational program
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.C.
      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.
      , self-management educational programs
      • Crotty M.
      • Prendergast J.
      • Battersby M.W.
      • Rowett D.
      • Graves S.E.
      • Leach G.
      • et al.
      Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial.
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • Mscule F.
      • Quinto L.
      • Hernandez M.V.
      • 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.
      , acupuncture
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term 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.
      and neuromuscular electrical stimulation
      • Walls R.J.
      • McHugh G.
      • O’Gorman D.J.
      • Moyna N.N.M.
      • O’Byrne J.M.
      Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty. A pilot study.
      .
      For participants awaiting hip joint replacement nine trials
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      • Berge D.J.
      • Dolin S.J.
      • Williams A.C.
      • Harman H.
      Pre-operative and post-operative effect of a pain management programme prior to total hip replacement: a randomized controlled trial.
      • Crotty M.
      • Prendergast J.
      • Battersby M.W.
      • Rowett D.
      • Graves S.E.
      • Leach G.
      • et al.
      Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial.
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip 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.
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • 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.
      investigated pre-operative interventions vs standard care. Exercise was the most common intervention in four trials
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • 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.
      for hip osteoarthritis. Formal educational programs combined with exercise programs were included in three trials
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip 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.
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      . Other interventions included a self-management program
      • Crotty M.
      • Prendergast J.
      • Battersby M.W.
      • Rowett D.
      • Graves S.E.
      • Leach G.
      • et al.
      Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial.
      (which also included participants with knee osteoarthritis) and a multidisciplinary pain management program
      • Berge D.J.
      • Dolin S.J.
      • Williams A.C.
      • Harman H.
      Pre-operative and post-operative effect of a pain management programme prior to total hip replacement: a randomized controlled trial.
      .

       Adverse events, recruitment of participants, adherence to intervention

      Eight of the 23 trials reported if adverse events occurred directly related to the intervention
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term 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.
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • 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.
      • 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.
      • Tillu A.
      • Roberts C.
      • Tillu S.
      Unilateral versus bilateral acupuncture on knee function in advanced osteoarthritis of the knee – a prospective randomised trial.
      . Minor adverse events were reported in three trials resulting from acupuncture interventions such as minor bruising or bleeding
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term 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.
      • Tillu A.
      • Roberts C.
      • Tillu S.
      Unilateral versus bilateral acupuncture on knee function in advanced osteoarthritis of the knee – a prospective randomised trial.
      . In one trial of acupuncture one vaso-vagal, and one large haematoma was reported
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term study.
      . No adverse events were reported in four of the exercise intervention trials
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      • 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.
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • 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.
      , except for one trial which reported short-term minor musculoskeletal soreness
      • 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.
      .
      Fourteen trials reported data on whether eligible participants declined to participate in the trials
      • Berge D.J.
      • Dolin S.J.
      • Williams A.C.
      • Harman H.
      Pre-operative and post-operative effect of a pain management programme prior to total hip replacement: a randomized controlled trial.
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term study.
      • Crotty M.
      • Prendergast J.
      • Battersby M.W.
      • Rowett D.
      • Graves S.E.
      • Leach G.
      • et al.
      Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial.
      • 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.
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip 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.
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • Mscule F.
      • Quinto L.
      • Hernandez M.V.
      • 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.
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • 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.
      • 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.
      • 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.
      • Mitchell C.
      • Walker J.
      • Walters S.
      • Morgan A.B.
      • Binns T.
      • Mathers N.
      Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial.
      • Tillu A.
      • Roberts C.
      • Tillu S.
      Unilateral versus bilateral acupuncture on knee function in advanced osteoarthritis of the knee – a prospective randomised trial.
      . The rate of non-participation was variable between trials ranging from 0%
      • 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.
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • Mscule F.
      • Quinto L.
      • Hernandez M.V.
      • 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.
      • 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.
      to 88%
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      . Recruitment of eligible participants was reported to be difficult in four trials
      • 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.
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Mitchell C.
      • Walker J.
      • Walters S.
      • Morgan A.B.
      • Binns T.
      • Mathers N.
      Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial.
      with the most common reasons being transportation difficulties, time commitments, energy levels and motivation. Adherence to the interventions was high with more than 80% of scheduled sessions attended in eight of ten interventions that recorded these data
      • 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.
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.C.
      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.
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • Mscule F.
      • Quinto L.
      • Hernandez M.V.
      • 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.
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • Walls R.J.
      • McHugh G.
      • O’Gorman D.J.
      • Moyna N.N.M.
      • O’Byrne J.M.
      Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty. A pilot 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.
      • 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.
      . In the pre-operative period common reasons for dropping out of the intervention included cancellation or postponement of surgery, having early surgery, medical reasons and time commitments. In the post-operative period patients were lost to follow-up for reasons such as complications post-surgery.
      Table IIaSummary of included trials: Pre-operative interventions for knee osteoarthritis vs standard care
      Study (country)Participants (intervention)Participants (standard care)InterventionOutcome measuresResults pre-operatively (SMD or MD, 95% CI)
      SMD or MD reported for underlined outcomes and timeframes.
      Results post-operatively (SMD or MD, 95% CI)
      SMD or MD reported for underlined outcomes and timeframes.
      Aoki et al. 2009
      • 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.
      (Japan)
      n=17n=19Exercise: Home-based, knee flexibility (knee flexion). Duration: every day up until surgery, 30 s holds, minimum of 10 reps at least ×1 daily.Pain:VAS (during gait)0.30 [−0.35, 0.96]N/A
      Age (yrs)=72.3 (5.2)Age (yrs)=74.4 (6.4)Activity limitation:Gait speed (m/min)0.47 [−0.20, 1.13]N/A
      BMI=26.6 (3.5)BMI=25.8 (2.4)Impairment:Knee flexion ROM0.41 [−0.25, 1.07]N/A
      Female (%)=100Female (%)=100
      OWL (days)=81 (32)OWL (days)=82 (32)Timeframe:PRE
      Duration (yrs): 10 (7)Duration (yrs): 9 (8)
      Beaupre et al. 2004
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.C.
      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.
      (Canada)
      n=65n=66Exercise and Education: Group. Ex: knee flexibility and strength training. Edu: post-operative care e.g., crutch walking, bed mobility. Duration: 4/52, 3× week.Pain:WOMAC−0.07 [−0.44, 0.31]0.06 [−0.31, 0.44]
      Age (yrs)=67 (7)Age (yrs)=67 (6)Activity limitation:WOMAC−0.06 [−0.44, 0.31]0.00 [−0.38, 0.38]
      Female (%)=60Female (%)=50Impairment:Knee flexion ROM0.26 [−0.12, 0.63]0.00 [−0.38, 0.38]
      BMI=32 (6)BMI=31 (5)Impairment:Quads Str, Hams Str0.09 [−0.32, 0.51]0.00 [−0.41, 0.41]
      Quality of life:SF-36 (8 sections, MSC, PSC)−0.28 [−0.66, 0.10]−0.09 [−0.47, 0.28]
      Service utilisation:LOS, discharge destinationN/AMD=0.60 days [−0.26, 1.46]
      Timeframe:PRE; POST 12w, 26w, 52w
      D’Lima et al. 1992
      • 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.
      (Canada)
      n=10Exercise: PT: knee flexibility, strength training (UL and LL). Duration: 6/52, 3× week, 45 min sessions.Combined:HSS, AIMS0.18 [−0.70, 1.06]0.02 [−0.86, 0.90]
      Age (yrs)=68.5 (4.6)Quality of life:Quality of wellbeing
      Sufficient data not reported.
      Sufficient data not reported.
      Female (%)=80(3 Rheumatoid pts)n=10 Age (yrs)=69.5 (6.5) Female (%)=50 (1 Rheumatoid pt)=50Service utilisation:LOSN/AMD=−0.21 days [−1.09, 0.67]
      Timeframe:PRE; POST 3w, 12w, 24w, 48w
      n=10
      Age (yrs)=71.6 (6.6)Aerobic training: Land and pool-based. Duration: 6/52, 3× week, 45 min sessions.Combined:HSS, AIMS0.43 [−0.46, 1.32]−0.88 [−1.80, 0.05]
      Female (%)=70Quality of life:Quality of wellbeing
      Sufficient data not reported.
      Sufficient data not reported.
      (1 Rheumatoid pt)Service utilisation:LOSN/AMD=−0.02 days [−0.98, 0.94]
      Evgeniadis et al. 2008
      • 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.
      (Greece)
      n=18n=20Exercise: Group, strength training for trunk and UL only. Supervised by PT and orthopaedist. Duration: 3/52, 3× week. Intensity: modest fatigue.Activity limitation:ILAS:N/A0.27 [−0.37, 0.91]
      Age (yrs)=67.1 (4.4) Female (%)=83.3 BMI=34.7 (5.3)Age (yrs)=69.4 (1.9) Female (%)=70 BMI=33.5 (4.7)(& timeframe)POST 3 days, 2w, 6w, 10w, 14w
      Impairment:Knee flex & Ext ROM.MD=3.20° [−3.67, 10.07]MD=−2.78° [−8.30, 2.74]
      (& timeframe)PRE, POST 2w, 10w, 14w
      Quality of life:SF-36 (8 sections)P0.05 for all sections.N/A
      (& timeframe)PREe.g., 0.35 [−0.29, 1.00] mental health (section 8)
      Rooks et al. 2006
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      (USA)
      n=22n=23Exercise: PT. Individual. Land- and pool-based supervised by PT. Strength training, bike, flexibility. Duration: 6/52, 3× week.Pain:WOMAC0.05 [−0.67, 0.78]0.10 [−0.63, 0.83]
      Age (yrs)=65 (8) Female (%)=50 BMI=35.7 (9.2)Age (yrs)=69 (8)Activity limitation:WOMAC, functional reach−0.22 [−0.95, 0.51]−0.10 [−0.83, 0.63]
      Female (%)=57Activity limitation:TUGT−0.77 [−1.53, −0.01]∗0.13 [−0.60, 0.86]
      BMI=33.9 (6.5)Impairment:1 Rep Max (leg press)0.32 [−0.41, 1.06]0.28 [−0.45, 1.01]
      Quality of life:SF-36 (3 sections, Role Limit)−0.98 [−1.76, −0.21]∗−0.02 [−0.75, 0.71]
      Service utilisation:discharge destinationP0.05P0.05
      Timeframe:PRE; POST 8w, 26w
      Topp et al. 2009
      • 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.
      (USA)
      n =26n=28Exercise: Strength training, supervised by the researcher. Duration: 3× week, 1 session each week. Intensity: moderate.Pain:VAS (During STS, up/down stairs & 6 mwt).0.88 [0.31, 1.44]∗−0.08 [−0.62, 0.45]
      Age (yrs)=64.1 (7.1) Female (%)=73 BMI=32.2 (5.9)Age (yrs)=63.5 (6.7) Female (%)=64 BMI=32 (6.1)(P0.05 for all except∗)(P0.05 for all)
      Activity limitation:6 mwt (metres), up/down stairs (time), STS (no.)0.32 [−0.22, 0.86]−0.09 [−0.63, 0.44]
      P0.05 for allP0.05 for all
      Impairment:Quads Str0.08 [−0.46, 0.61]0.06 [−0.47, 0.59]
      Timeframe:PRE; POST 4w, 12w
      Weidenhielm et al. 1993
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      (Sweden)
      n=19n=20Exercise: PT: Group setting: LL strengthening, bike, knee flexibility. Home exercise recommended. Duration: 5/52, 3× week (15 sessions).Pain:4 point scale
      Sufficient data not reported.
      Sufficient data not reported.
      Age (yrs)=64 (4)Age (yrs)=63 (5)Pain:10 point scale during walk−0.22 [−0.85, 0.41]−0.18 [−0.80, 0.45]
      Female (%)=58Female (%)=45Activity limitation:Walk speed (self-selected)0.28 [−0.35, 0.91]−0.23 [−0.86, 0.40]
      BMI=30.1BMI=29.1Activity limitation:Walk speed (maximal)0.03 [−0.60, 0.65]−0.28 (−0.91, 0.35]
      Unicompartment replacementImpairment:Knee ROM0.07 [−0.56, 0.70]0.31 [−0.32, 0.94]
      Impairment:Quads Str0.42 [−0.21, 1.06]−0.36 [−0.99, 0.27]
      Timeframe:PRE (3 months, immediate);
      POST 12w
      n=60Exercise: PT. Group setting, strength, balance, flexibility. Duration: 6/52, 1 h sessions, ×1 weekly.Pain:VAS0.37 [0.01, 0.73]∗0.03 [−0.32, 0.39]
      Age (yrs)=70 (8.8)Activity limitation:WOMAC0.17 [−0.19, 0.53]−0.08 [−0.44, 0.28]
      Female (%)=52Activity limitation:Timed 50m walk0.24 [−0.12, 0.60]−0.26 [−0.62, 0.09]
      Williamson et al. 2007
      • 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.
      (UK)
      BMI=32.8 (5.7)n=61Combined:OKS0.24 [−0.12, 0.59]−0.18 [−0.54, 0.17]
      Age (yrs)=69.6 (10) Female (%)=54 BMI=32.7 (6.5)Quality of life:HADanxiety, depression−0.12 [−0.47, 0.24]−0.55 [−0.91, −0.19]∗
      Service utilisation:LOSMD=0.11 days [−0.72, 0.94]
      Timeframes:PRE (1w & 6w post-intervention)
      Timeframes:POST 12w
      n=60Acupuncture: PT. Group setting. Duration: 6/52, 1× week.Pain:VAS0.30 [−0.06, 0.66]0.38 [0.02, 0.74]∗
      Age (yrs)=72.4 (7.7)Activity limitation:WOMAC0.25 [−0.11, 0.61]0.21 [−0.15, 0.57]
      Female (%)=55Activity limitation:Timed walk (50m)0.15 [−0.20, 0.51]−0.35 [−0.71, 0.01]
      BMI=30.9 (6.0)Combined:OKS0.36 [0.00, 0.70]∗0.13 [−0.22, 0.49]
      Quality of life:HAD – anxiety, depression−0.08 [−0.44, 0.27]−0.08 [−0.44, 0.27]
      Service utilisation:LOSMD=−1.17 days [−2.37, 0.03]
      Christensen et al. 1992
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term study.
      (Denmark)
      n=14n=15Acupuncture: Duration: 3/52, 2× week.Pain:VAS
      Sufficient data not reported.
      N/A
      Age (yrs)=69.2 (7.8)Age (yrs)=69.2 (7.8)Activity Limitation:Timed Stair climb (20 steps)0.90 [0.13, 1.67]∗N/A
      Female (%)=71Female (%)=66.7Activity Limitation:Timed walk (50m)1.00 [0.22, 1.78]∗N/A
      Impairment:Knee ROM
      Sufficient data not reported.
      N/A
      Combined:HSS1.02 [0.24, 1.80]∗N/A
      Timeframe:PRE (1w & 4 w post-intervention)
      Nunez et al. 2006
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • Mscule F.
      • Quinto L.
      • Hernandez M.V.
      • 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.
      (Spain)
      n=51n =49Self-Management Program: Therapeutic education and functional readaption: Group, lead by health educator on social learning, OA edu & exercise. Duration: 3/12, 2× individual & 3× group sessions.Pain:WOMAC0.23 [−0.21, 0.67]N/A
      Age (yrs)=72.6 (6.2)Age (yrs)=69.5 (6.8)Activity Limitation:WOMAC0.48 [0.04, 0.93]∗N/A
      Female (%)=76.5Female (%)=65.3Quality Of Life:SF-36 (Spanish)
      Duration (yrs): 1Duration (yrs): 0.97Quality Of Life:- physical function0.21 [−0.23, 0.66]N/A
      Quality Of Life:- bodily pain0.35 [−0.09, 0.80]N/A
      Quality Of Life:- all other itemsall P0.05N/A
      Timeframe:PRE
      Walls et al. 2010
      • Walls R.J.
      • McHugh G.
      • O’Gorman D.J.
      • Moyna N.N.M.
      • O’Byrne J.M.
      Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty. A pilot study.
      (Ireland)
      n=9n=5NMES: Duel channel, symmetrical, biphasic square waveform, 5 s on, 10 s relax, ramp up 1 and 0.5 s down, 16.5 s cycle. 4 electrodes placed over quads (VL and VM) in sitting. Duration: 8/52, 20 min alternate days for 2 weeks, then daily for 6 days before operation.Pain:WOMAC0.11 [−0.99, 1.20]−0.05 [−1.14, 1.05]
      Age (yrs)=64.4 (8)Age (yrs)=63.2 (11.4)Activity limitation:WOMAC0.28 [−0.82, 1.38]0.12 [−0.97, 1.22]
      Female (%)=67Female (%)=80Activity limitation:Timed stair climb (11 steps)0.70 [−0.43, 1.84]1.14 [−0.06, 2.34]
      BMI=30.7 (3)BMI=32.8 (6.3)Activity limitation:Timed chair rise (3 times)1.13 [−0.07, 2.33]1.14 [−0.06, 2.34]
      Activity limitation:Timed walk (25m)0.83 [−0.32, 1.98]0.73 [−0.41, 1.87]
      Impairment:Quads torque1.02 [−0.16, 2.20]1.02 [−0.16, 2.20]
      Quality of life:SF-36 (PCS)−0.06 [−1.15, 1.03]0.00 [−1.09, 1.10]
      Quality of life:SF-36 (MCS)−0.30 [−1.40, 0.80]0.32 [−0.78, 1.43]
      Service utilisation:LOS, discharge destination
      Sufficient data not reported.
      Sufficient data not reported.
      Timeframe:PRE; POST 6w, 12w
      N/A=Timeframe not applicable.
      Abbreviations: PRE=pre-operative, POST=post-operative, LOS=length of stay, Edu=education, PT=Physiotherapist, OT=Occupational Therapist, BMI=Body Mass Index, OWL=number of days spent on waiting list for surgery, Yrs=years, Str=strength, UL=upper limb, LL=lower limb, HEP=home exercise program, w=weeks, s=seconds, ROM=range of movement, Ab=Abduction, Flex=flexion, 6 mwt=six minute walk test, 4mwt=four minute walk test, VAS=visual analogue scale, ILAS=Iowa level of assistance scale, LAPAQ=LASA physical activity score, AQoL=Assessment of quality of life scale, CES-D=centre of epidemiologic studies depression scale, BMQ=beliefs about medicines questionnaire, STS=sit to stand, SF-36=Short Form 36 Health Survey (MCS=mental health Composite Score, PCS=physical health composite score), WOMAC=Western Ontario and McMaster Universities Arthritis Index, HSS=Hospital for Special Surgery Knee Score, HOOS=Hip Osteoarthritis Outcome Score, HHS=Harris Hip Score, TUGT=Timed up and go test, OKS=Oxford Knee Score, HAD=Hospital anxiety and depression scale, AIMS=Arthritis impact measurement scale. RPE=rate of perceived exertion.
      P<0.05.
      SMD or MD reported for underlined outcomes and timeframes.
      Sufficient data not reported.
      Table IIbSummary of included trials: Pre-operative interventions for hip osteoarthritis vs standard care
      Study (Country)Participants (intervention)Participants (standard care)InterventionOutcome measuresResults pre-operatively (SMD or MD, 95% CI)
      SMD or MD reported for underlined outcomes and timeframes.
      Results post-operatively (SMD or MD, 95% CI)
      SMD or MD reported for underlined outcomes and timeframes.
      Gilbey et al. 2003
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      (Australia)
      n=37n=31Exercise: Land, pool-based & home-based. Aerobic, strength training and flexibility. Duration: 8/52, hourly sessions, 2 clinic (supervised) & 2 home-based sessions weekly.Activity Limitation:WOMAC0.57 [0.03, 1.10]0.53 [−0.01, 1.06]
      Age (yrs)=66.7(10)Age (yrs)=63.3 (12)Combined:WOMAC0.63 [0.09, 1.17]∗0.53 [−0.01, 1.06]
      Female (%)=56.8Female (%)=67.7Impairment:Hip Flex ROMMD=4.70° [0.10, 9.30]MD=6.00° [0.12, 11.88]
      BMI=27.7 (4.8)BMI=28.2 (3.6)LL strength (combined)0.54 [0.01, 1.07]∗N/A
      TOTAL OA%=87%Timeframe:PRE; POST 3w, 12w∗∗, 24w∗∗∗∗Intervention group received intervention POST 3–12w
      Hoogeboom et al. 2010
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      (Netherlands)
      n=10n=11Exercise: PT: individual. E.g., Strength training, bike. Duration: 3–6/52, ×2 week, 60 min sessions. Exercise intensity: 13–14/20 RPE (moderately high).Pain:HOOS0.39 [−0.50, 1.28]N/A
      Age (yrs)=77 (2.8)Age (yrs)=75 (5.3)Pain:VAS0.51 [−0.38, 1.40]N/A
      Female (%)=70Female (%)=63.6Activity limitation:HOOS (ADL function)−0.07 [−0.95, 0.81]N/A
      BMI=26 (2.6)BMI=27.4 (4.2)Activity limitation:TUGT, functional reach0.43 [−0.45, 1.32]N/A
      OWL (days)=29 (7)OWL (days)=34 (14)Activity limitation:6mwt0.15 [−0.73, 1.03]N/A
      Activity limitation:Timed chair rise0.39 [−0.49, 1.28]N/A
      Activity limitation:PSFS (5 items combined)0.41 [−0.47, 1.30]N/A
      Activity limitation:PWC-170−0.24 [−1.12, 0.64]N/A
      Activity limitation:LAPAQ0.00 [−0.88, 0.88]N/A
      Quality of life:HOOS (QOL)−0.43 (−1.32, 0.46]N/A
      Service utilisation:LOS−1.00 [−1.94, −0.06]∗N/A
      Timeframe:PRE
      Rooks et al. 2006
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      (USA)
      n=32n=31Exercise: PT. Land- and pool-based. Individual strength training, bike & flexibility. Duration: 6/52, 3× week.Pain:WOMAC0.58 [0.01, 1.15]∗0.04 [−0.52, 0.60]
      Age (yrs)=65 (11) Female (%)=63 BMI=28.4 (5.3)Age (yrs)=59 (7)Activity limitation:WOMAC functional reach0.59 [0.01, 1.16]∗0.01 [−0.55, 0.57]
      Female (%)=51Activity limitation:TUGT−0.02 [−0.58, 0.54]−0.24 [−0.80, 0.33]
      BMI=30.3 (9.1)Impairment:1 Rep Max (leg press)−0.02 [−0.58, 0.54]−0.60 [−1.18, −0.03]
      Quality of life:SF-36 (3 sections, Role Limit)0.32 [−0.24, 0.89]0.02 [−0.54, 0.58]
      Service utilisation:discharge destinationP0.05P0.05
      Timeframe:PRE; POST 8w, 26w
      Wang et al. 2002
      • 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.
      (Australia)
      n=15n=13Exercise: Clinic. Supervised. Land, pool-based & home-based. Strength training, aerobic & flexibility. Duration: 8/52, 2 clinic/pool sessions for 1-h & 2 home-based sessions per week.Activity limitation:Gait velocity0.17 [−0.57, 0.92]1.01 [0.21, 1.80]∗
      Age (yrs)=68.3 (8.2)Age (yrs)=65.7 (8.4)Activity limitation:Stride length0.26 [−0.49, 1.01]0.73 [−0.04, 1.50]
      Female (%)=60Female (%)=69.2Activity limitation:Cadence0.26 [−0.49, 1.01]1.03 [0.23, 1.82]∗
      TOTAL OA%=89%Activity limitation:6 mwt∗∗N/AN/A
      Subset of Gilbey et al. 2003
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      Timeframe:PRE; POST 3w, 12w∗∗, 24w∗∗∗∗Intervention group received intervention POST 3–12w.
      Ferrara et al. 2008
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      (Italy)
      n=11n=12Exercise and Education: PT. Group and Individual. Edu: post-operative advice. Ex: LL strength training, ex bike, flexibility. Duration: 4/52, 5× week. 60 min sessions. 40 mins group, 20 mins individually. Intensity of bike: low–moderate.Pain:VAS0.83 [−0.03, 1.68]1.17 [0.29, 2.06]∗
      Age (yrs)=63.8 (9.0)Age (yrs)=63.1 (6.9)Pain:WOMAC0.78 [−0.07, 1.63]0.23 [−0.59, 1.06]
      Female (%)=63.6Female (%)=58.3Activity limitation:WOMAC, Bartel0.8 [−0.05, 1.65]0.88 [0.02, 1.74]∗
      Combined:HHS0.54 [−0.03, 1.37]0.33 [−0.49, 1.16]
      Impairment:Hip Ab ROMMD=−0.27° [−9.47, 8.93]MD=3.91° [−0.57, 8.39]
      Impairment:Hip ER ROMMD=7.69° [1.28, 14.10]∗MD=−0.14° [−3.67, 3.39]
      Impairment:Quads Str0.46 [−0.37, 1.29]
      Sufficient data not reported.
      Impairment:Hip Ab Str1.63 [0.67, 2.60]∗
      Sufficient data not reported.
      Quality of life:SF-36 (PCS)0.86 [0.00, 1.72]∗−0.62 [−1.46, 0.22]
      Quality of life:SF-36 (MCS)0.86 [0.00, 1.72]∗0.21 [−0.61, 1.03]
      Timeframe:PRE; POST 15 days, 4w, 12w
      Gocen et al. 2004
      • 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.
      (Turkey)
      n=29n=30Exercise and Education: PT. Individual. Strength Training (UL & LL) & flexibility. Edu: about living with a prosthesis. Duration: 8/52, fortnightly PT sessions. Home ex’s 3× daily, 10 reps.Activity limitation:First day walkingN/AMD=0.13 days [−0.03, 0.29]
      Age (yrs)=46.9(11.5)Age (yrs)=55.5(14.4)(During inpatient stay post-operative)First day climbing stairsN/AMD=1.2days [0.48, 1.92]∗
      Female (%)=55.2Female (%)=73.3First day bed transfersN/AMD=0.4days [0.07, 0.73]∗
      BMI=24.9 (3.7)BMI=27.7 (3.7)First day chair transferN/AMD=1.36days [0.78, 1.94]∗
      First day toilet transferN/AMD=0.83days [0.34, 1.32]∗
      Combined:HHS0.39 [−0.13, 0.90]0.61 [0.09, 1.14]∗ POST 12w
      Impairment:Hip Ab ROMMD=2.20° [−3.53, 7.73]N/A
      Timeframe:PRE; POST Inpatient stay, d/c day, 12w, 104w
      Vukomanovic et al. 2008
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      (Belgrade)
      n=23n=22Exercise and Education: Exercise: Two classes by PT including post-operative mobility practice. Education by physiatrist (pre & post-operative advice). Duration: 2 exercise sessions, 1 education session.Pain:VAS (at rest, on move)−0.14 [0.73, 0.44]0.16 [−0.50, 0.81]
      Age (yrs)=60.1(11)Age (yrs)=56.2(18.5)Activity Limitation:First day walkingN/AMD=0.35days [0.02, 0.68]∗
      Female (%)=70Female (%)=80(During inpatient stay post-operative)First day climbing stairsN/AMD=1.67days [0.70, 2.64]∗
      Duration: 8.1 (5.9)Duration: 6.3 (7.5)First day chair transferN/AMD=1.05days[0.36, 1.74]∗
      First day toilet transferN/AMD=0.90days [0.22, 1.58]∗
      Performance Day 3 and D/C∗N/A∗all P<0.05
      Impairment:Hi Ab ROMMD=−2.75° [−7.81, 2.31]MD=−1.75° [−7.25, 3.75] POST 60w
      Impairment:Hip Flex ROMMD=−6.50° [−18.90, 5.90]MD=0.75° [−7.67, 9.17] POST 60w
      Combined:HHS, Oxford Hip Score, JOA−0.18 [−0.76, 0.41]0.16 [−0.50, 0.81] POST 60w
      Service utilisation:LOSMD=0.40 days [−0.89, 1.69]
      Timeframe:PRE;
      POST Inpatient stay, POST 60w
      Berge et al. 2004
      • Berge D.J.
      • Dolin S.J.
      • Williams A.C.
      • Harman H.
      Pre-operative and post-operative effect of a pain management programme prior to total hip replacement: a randomized controlled trial.
      (UK)
      n=19n=21Pain Management Program: Clinical psychologist, OT & PT. Group format. Sessions on OA education, cognitive behavioural methods and relaxation methods. Duration: 6/52 (21.5 h), 1–2 sessions × week.Pain:VAS (0–10 scale)0.98 [0.29, 1.66]∗0.26 [−0.43, 0.95]
      Age (yrs)=71.6 (6)Age (yrs)=71(6.1)Activity limitation:4 mwt0.39 [−0.26, −1.04]0.10 [−0.59, 0.78]
      Female (%)=63Female (%)=71Quality of lifeAIMS depression0.25 [−0.39, 0.90]0.08 [−0.61, 0.76]
      OWL (days)=>183OWL (days)=>183Quality of lifeAIMS anxiety0.23 [−0.42, 0.88]0.52 [−0.18, 1.22]
      Timeframe:PRE (12w post-intervention); POST 32 (average)
      Crotty et al. 2009
      • Crotty M.
      • Prendergast J.
      • Battersby M.W.
      • Rowett D.
      • Graves S.E.
      • Leach G.
      • et al.
      Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial.
      ,
      Outcomes were not able to be separated for hip and knee OA participants.
      (Australia)
      n=75n=77Self-Management Program: Flinders University ‘partners in health model.’ Pts pick 0 to 3 out of: (1) Self-management course. Duration: 6/52, 2.5 h weekly. (2) Joint replacement education. Duration: 2/52, 2.5 h & (3) Peer support telephone calls.Pain:WOMAC0.43 [0.11, 0.75]∗N/A
      Age (yrs)=68.1(10.6)Age (yrs)=67(11)Activity limitation:WOMAC1.02 [0.69, 1.36]∗N/A
      Female (%)=60Female (%)=61Quality of life:AQoL0.72 [0.40, 1.05]∗N/A
      No. of TKR=50No. of TKR=52Quality of life:CES-D, HEIQ, BMQ−0.25 [−0.57, 0.07]N/A
      No. of THR=25No. of THR=25Timeframe:PRE (average 27w post-intervention)
      BMI=31.5BMI=29.8
      N/A=Timeframe not applicable.
      P<0.05
      SMD or MD reported for underlined outcomes and timeframes.
      Sufficient data not reported.
      § Outcomes were not able to be separated for hip and knee OA participants.
      Table IIcSummary of included trials: Pre-operative interventions compared with another intervention for knee and hip osteoarthritis
      Study (Country)Participants (Intervention 1)Participants (Intervention 2)Intervention 1 and 2Outcome measuresResults (SMD or MD, 95% CI)
      SMD or MD reported for underlined outcomes and timeframes.
      Haslam et al. 2001
      • Haslam R.
      A comparison of acupuncture with advice and exercises on the symptomatic treatment of osteoarthritis of the hip – a randomised controlled trial.
      (UK)

      Hip
      n=16n=121: Acupuncture: Side lying. Duration: 6/52, 6 sessions, first session 10 mins, subsequent sessions 25 mins.Combined:WOMAC (modified)0.50 [−0.26, 1.27]
      Age (yrs)=66 (9.5)Age (yrs)=69.4 (5)Timeframe:PRE (immediately & 8w post-intervention)
      Female (%)=81.3Female (%)=66.72: Exercise & Education: PT. Individual. Ex’s-5 for HEP. Education on OA and self-help. Duration: 6/52. 3 sessions, 30 mins.
      Duration (yrs): 9Duration (yrs): 9
      Gill et al. 2009
      • 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.
      (Australia)

      Hip and Knee
      n=40n=421: Exercise PT (land-based), Education & OT home visit: Ex: strength training, flexibility, walking. Moderate intensity (RPE: 12–14). Duration: 6/52, ×2 weekly, 1 h sessions. Edu: 1×1 h session (OA, disability & principles of health exercise). OT: 1× home visit. All pt’s encouraged to complete 30 min HEP.Pain:WOMAC0.10 [−0.38, 0.59]
      Age (yrs)=71.6 (8.9)Age (yrs)=69.2 (10.5)Activity limitation:WOMAC0.03 [−0.45, 0.52]
      Female (%)=57.5Female (%)=66.6Activity limitation:Timed 50 foot walk0.10 [−0.39, 0.59]
      BMI=31.0 (5.3)BMI=31.1 (5.9)Activity limitation:Chair rise test (30s)0.33 [−0.16, 0.83]
      OA %=97.5OA%=97.6Quality of life:SF-36 (MCS)0.06 [−0.42, 0.54]
      2: Exercise PT (pool-based), Education & OT home visit. Details as per intervention group.Timeframe:PRE (immediately and 8w post-intervention)
      Tillu et al. 2001
      • Tillu A.
      • Roberts C.
      • Tillu S.
      Unilateral versus bilateral acupuncture on knee function in advanced osteoarthritis of the knee – a prospective randomised trial.
      (UK)

      Knee
      n=22n=221: Acupuncture (unilateral knee). Duration: 6/52, 1× weekly.Pain:VAS0.07 [−0.34, 0.49]
      Age (yrs)=72 (9.3)Age (yrs)=73 (7)Activity limitation:Timed stair climb (20 steps)0.15 [−0.27, 0.57]
      Female (%)=82Female (%)=772: Acupuncture (bilateral knee). Duration: 6/52, 1× weekly.Activity limitation:Timed 50m walk0.20 [−0.22, 0.62]
      Combined:HSS0.25 [−0.17, 0.67]
      Timeframe:PRE (8w & 26w post-intervention)
      Mitchell et al. 2005
      • Mitchell C.
      • Walker J.
      • Walters S.
      • Morgan A.B.
      • Binns T.
      • Mathers N.
      Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial.
      (UK)

      Knee
      n=57n=571: Physiotherapy home visits: manual therapy, exercise, gait re-education. Minimum 3 pre-operative and up to 6 post-operative visits.Pain:WOMAC0.02 [−0.34, 0.39]
      Age (yrs)=70 (7.2)Age (yrs)=70.6 (8.2)Activity limitation:WOMAC0.11 [−0.26, 0.47]
      Female (%)=63.2Female (%)=52.6Quality of life:SF-36 (8 items)P0.05 for all
      OWL (days)=31(13)OWL (days)=25 (13)2: Physiotherapy: Outpatient and group program at discretion of physiotherapist. Duration 1–2× per week.Service utilisation:LOSMD=0.40 days [−0.79, 1.59]
      Timeframe:POST 12w
      SMD or MD reported for underlined outcomes and timeframes.

       Risk of bias within studies

      There were 12 higher quality trials (≥6/10) and the average score across all trials was 6/10. The most adhered to items on the PEDro scale were random allocation, measures of variability for at least one key outcome, and between group comparisons which were evident in almost all of the trials. None of the trials blinded participants or therapists which was expected given these items are the most difficult to adhere to in trials of interventions such as exercise. Eight trials used allocation concealment and 11 had blinded outcome assessors. Nine trials reported intention to treat analysis and 12 trials had measures of at least one key outcome from >85% of participants (Table III).
      Table IIIMethodological quality of the trials (PEDro)
      Trial1234567891011Total (/10)
      Aoki, 2009
      • 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.
      7
      Beaupre, 2004
      • Beaupre L.A.
      • Lier D.
      • Davies D.M.
      • Johnston D.B.C.
      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.
      7
      Berge, 2004
      • Berge D.J.
      • Dolin S.J.
      • Williams A.C.
      • Harman H.
      Pre-operative and post-operative effect of a pain management programme prior to total hip replacement: a randomized controlled trial.
      4
      Christensen, 1992
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term study.
      5
      Crotty, 2009
      • Crotty M.
      • Prendergast J.
      • Battersby M.W.
      • Rowett D.
      • Graves S.E.
      • Leach G.
      • et al.
      Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial.
      7
      D’Lima, 1992
      • 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.
      4
      Evgeniadis, 2008
      • 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.
      6
      Ferrara, 2008
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      7
      Gilbey, 2003
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      3
      Gill, 2009
      • 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.
      7
      Gocen, 2004
      • 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.
      6
      Haslam, 2001
      • Haslam R.
      A comparison of acupuncture with advice and exercises on the symptomatic treatment of osteoarthritis of the hip – a randomised controlled trial.
      4
      Hoogeboom, 2010
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      7
      Mitchell, 2005
      • Mitchell C.
      • Walker J.
      • Walters S.
      • Morgan A.B.
      • Binns T.
      • Mathers N.
      Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial.
      6
      Nunez, 2006
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • Mscule F.
      • Quinto L.
      • Hernandez M.V.
      • 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.
      5
      Rooks, 2006
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      4
      Tillu, 2001
      • Tillu A.
      • Roberts C.
      • Tillu S.
      Unilateral versus bilateral acupuncture on knee function in advanced osteoarthritis of the knee – a prospective randomised trial.
      7
      Topp, 2009
      • 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.
      5
      Vukomanovic, 2008
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      4
      Walls, 2010
      • Walls R.J.
      • McHugh G.
      • O’Gorman D.J.
      • Moyna N.N.M.
      • O’Byrne J.M.
      Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty. A pilot study.
      5
      Wang, 2002
      • 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.
      6
      Weidenhielm, 1993
      • Weidenhielm L.
      • Mattsson E.
      • Brostrom L.
      • Wersall-Robertsson E.
      Effect of preoperative physiotherapy in unicompartmental prosthetic knee replacement.
      5
      Williamson, 2007
      • 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.
      8
      PEDro Criteria: (1) Eligibility criteria specified. (2) Random allocation. (3) Allocation concealed. (4) Groups similar at baseline. (5) Participant blinding. (6) Therapist blinding. (7) Assessor blinding. (8) Measures of at least one key outcome were obtained from >85% of subjects. (9) Data were analysed by Intention to treat. (10) Results reported for at least one key outcome. (11) Point measures and measures of variability provided.

      Synthesis of results

       Effect of pre-operative exercise interventions vs standard care for knee osteoarthritis

      Meta-analysis of four trials with 240 participants provided moderate quality evidence that exercise interventions compared with standard care were effective for reducing pain for knee osteoarthritis prior to knee replacement (Fig. 2, Table IV).
      Figure thumbnail gr2
      Fig. 2SMD (95% CI) of effect of pre-operative exercise vs standard care on pain for participants with knee osteoarthritis prior to total knee replacement.
      Table IVMeta-analyses for pre-operative interventions vs standard care for knee osteoarthritis
      InterventionNo. of trials(Ref.)No. of participantsOutcomeTimeframeSMD (95% CI), I2MD (95% CI), I2Quality of the evidence (GRADE)
      Exercise4
      • 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.
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • 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.
      • 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.
      240Pain
      Gait performance measures=gait speed, timed up and go test, 6min walk test, timed 50m walk.
      Pre-operative0.43 [0.13, 0.73], 19%Moderate
      Reason for downgrade: Two trials38,39 rated lesser quality (PEDro<6) without blinded outcome measures and allocation concealment.
      Gait performance
      Gait performance measures=gait speed, timed up and go test, 6min walk test, timed 50m walk.
      Pre-operative0.12 [−0.30, 0.55], 58%Very low
      Reason for downgrade: As above but further downgrading and statistical heterogeneity (I2=58%) and large confidence interval.
      Exercise3
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • 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.
      • 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.
      204Pain
      Pain measures=VAS – visual analogue scale, WOMAC – Western Ontario and McMaster Universities Arthritis Index.
      Post-operatively 8–12 w0.01 [−0.26, 0.29], 0%Moderate
      Reason for downgrade: Two trials38,39 rated lesser quality (PEDro<6) without blinded outcome measures and allocation concealment.
      Gait performance
      Gait performance measures=timed up and go test, 6min walk test, timed 50m walk.
      Post-operatively 8–12 w−0.16 [−0.44, 0.11], 0%Moderate
      Reason for downgrade: Two trials38,39 rated lesser quality (PEDro<6) without blinded outcome measures and allocation concealment.
      Exercise2
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • 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.
      150WOMAC functionPre-operative0.09 [−0.23, 0.42], 0%Moderate
      Reason for downgrade: One trial38 rated lesser quality (PEDro=4) without blinded outcome measures and allocation concealment.
      Post-operatively 8–12 w−0.08 [−0.40, 0.24], 0%Moderate
      Reason for downgrade: One trial38 rated lesser quality (PEDro=4) without blinded outcome measures and allocation concealment.
      Exercise2
      • 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.
      • 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.
      141Hospital length of stay0.01 [−0.32, 0.34], 0%−0.04 days [−0.64, 0.56], 0%Moderate
      Reason for downgrade: One trial31 rated lesser quality (PEDro=4).
      Acupuncture2
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term 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.
      150Timed 50 m walkPre-operative0.50 [−0.31, 1.32], 73%10.46 s [−5.24, 26.16], 75%Very low
      Reason for downgrade: One trial29 rated lesser quality (PEDro=5), statistical heterogeneity (I2=73%), very large confidence interval.
      GRADE=GRADE working group grades of evidence (see Reason for downgrade).
      Pain measures=VAS – visual analogue scale, WOMAC – Western Ontario and McMaster Universities Arthritis Index.
      Gait performance measures=gait speed, timed up and go test, 6 min walk test, timed 50 m walk.
      Gait performance measures=timed up and go test, 6 min walk test, timed 50 m walk.
      § Reason for downgrade: Two trials
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • 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.
      rated lesser quality (PEDro<6) without blinded outcome measures and allocation concealment.
      Reason for downgrade: As above but further downgrading and statistical heterogeneity (I2=58%) and large confidence interval.
      Reason for downgrade: One trial
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      rated lesser quality (PEDro=4) without blinded outcome measures and allocation concealment.
      # Reason for downgrade: One 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.
      rated lesser quality (PEDro=4).
      ∗∗ Reason for downgrade: One trial
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term study.
      rated lesser quality (PEDro=5), statistical heterogeneity (I2=73%), very large confidence interval.
      Meta-analyses did not show any differences regarding activity performance prior to knee replacement, length of hospital stay, and for pain and activity performance at 2–3 months following surgery (Table IV).
      Individual trials that could not be included in meta-analyses due to heterogeneity or insufficient reporting did not show any differences for other outcomes including musculoskeletal impairments, quality of life and discharge destination (Table IIa).

       Effect of pre-operative exercise interventions vs standard care for hip osteoarthritis

      Meta-analysis of two trials with 69 participants provided low quality evidence that exercise interventions compared with standard care were effective for reducing pain prior to hip replacement (Fig. 3, Table V). Meta-analysis of three trials with 126 participants provided moderate quality evidence for improved activity prior to hip replacement (Fig. 4, Table V).
      Figure thumbnail gr3
      Fig. 3SMD (95% CI) of effect of pre-operative exercise vs standard care on pain for participants with hip osteoarthritis prior to total hip replacement.
      Table VMeta-analyses for pre-operative interventions vs standard care for hip osteoarthritis
      InterventionNo. of trials(Ref.)No. of participantsOutcomeTimeframeSMD (95% CI), I2MD (95% CI), I2Quality of the evidence (GRADE)
      Exercise2
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      69Pain
      Pain measures=HOOS – Hip Osteoarthritis Outcome score, WOMAC – Western Ontario and McMaster Universities Arthritis Index.
      Pre-operative0.52 [0.04, 1.01], 0%Low
      Reason for downgrade: One trial38 rated lesser quality (PEDro=4) without allocation concealment and assessor blinding, large confidence interval.
      Timed Up and Go TestPre-operative0.11 [−0.37, 0.58], 3%0.11 s [−1.40, 1.63], 3%Low
      Reason for downgrade: One trial38 rated lesser quality (PEDro=4) without allocation concealment and assessor blinding, large confidence interval.
      Exercise3
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.M.
      • Oosting E.
      • van Meeteren N.L.U.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      126Activity limitation
      Activity limitation measures=WOMAC function and HOOS function.
      Pre-operative0.47 [0.11, 0.83], 0%Moderate
      Reason for downgrade: Two trials24,25,30 rated lesser quality (PEDro<6) without allocation concealment and assessor blinding.
      Exercise2
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      106WOMAC functionPost-operative 3–8 w0.28 [−0.23, 0.78], 41%3.41 units [−4.23, 11.05], 65%Very low
      Reason for downgrade: All trials rated lesser quality (PEDro<6), statistical heterogeneity (I2=75%), large confidence interval.
      Ex & Edu2
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      68Pain – VASPre-operative0.29 [−0.66, 1.23], 70%Very low
      Reason for downgrade: One trial37 rated lesser quality (PEDro=4) without allocation concealment and assessor blinding, statistical heterogeneity (I2=70%), large confidence interval.
      Ex & Edu3
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip 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.
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      127Harris Hip ScorePre-operative0.21 [−0.20, 0.63], 26%2.99 units [−3.57, 9.54], 46%Moderate
      Reason for downgrade: Statistical heterogeneity (I2=26%), very large confidence interval.
      Hip abduction ROMPre-operative−0.02 [−0.37, 0.33], 0%−0.53° [−4.04, 2.97], 0%High
      Reason for downgrade: No downgrade.
      Ex & Edu2
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip 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.
      82Harris Hip ScorePost-operative 12 w0.53 [0.09, 0.97], 0%6.05units [1.29, 10.81], 0%Moderate
      Reason for downgrade: Large confidence interval.
      Ex & Edu2
      • 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.
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      99First day walkingPost-operative – inpatient stay0.50 [0.10, 0.90], 0%0.19days [0.00, 0.39], 28%Low
      Reason for downgrade: Large confidence interval.
      First day stair climb0.93 [0.51, 1.35], 0%1.37days [0.79, 1.94], 0%Low
      Reason for downgrade: One trial37 rated lesser quality (PEDro=4) without allocation concealment and assessor blinding, large confidence interval.
      First day using toilet0.82 [0.41, 1.24], 0%0.85days [0.46, 1.25], 0%Low
      Reason for downgrade: One trial37 rated lesser quality (PEDro=4) without allocation concealment and assessor blinding, large confidence interval.
      First day using chair1.06 [0.64, 1.48], 0%1.23days [0.78, 1.68], 0%Low
      Reason for downgrade: One trial37 rated lesser quality (PEDro=4) without allocation concealment and assessor blinding, large confidence interval.
      GRADE=GRADE working group grades of evidence (see reason for downgrade).
      Pain measures=HOOS – Hip Osteoarthritis Outcome score, WOMAC – Western Ontario and McMaster Universities Arthritis Index.
      Activity limitation measures=WOMAC function and HOOS function.
      Reason for downgrade: One trial
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      rated lesser quality (PEDro=4) without allocation concealment and assessor blinding, large confidence interval.
      § Reason for downgrade: Two trials
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      • Crotty M.
      • Prendergast J.
      • Battersby M.W.
      • Rowett D.
      • Graves S.E.
      • Leach G.
      • et al.
      Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial.
      rated lesser quality (PEDro<6) without allocation concealment and assessor blinding.
      Reason for downgrade: All trials rated lesser quality (PEDro<6), statistical heterogeneity (I2=75%), large confidence interval.
      Reason for downgrade: One trial
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      rated lesser quality (PEDro=4) without allocation concealment and assessor blinding, statistical heterogeneity (I2=70%), large confidence interval.
      # Reason for downgrade: Statistical heterogeneity (I2=26%), very large confidence interval.
      ∗∗ Reason for downgrade: No downgrade.
      †† Reason for downgrade: Large confidence interval.
      ‡‡ Reason for downgrade: One trial
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      rated lesser quality (PEDro=4) without allocation concealment and assessor blinding, large confidence interval.
      Figure thumbnail gr4
      Fig. 4SMD (95% CI) of effect of pre-operative exercise vs standard care on activity limitation (WOMAC, HOOS function) for participants with hip osteoarthritis prior to total hip replacement.
      Meta-analyses did not show any differences for activity prior to hip replacement and for WOMAC function score for 3–8 weeks post-operatively (Table V).
      Individual trials not able to be combined in meta-analysis due to heterogeneity did not show any differences for musculoskeletal impairments, quality of life, length of stay, and discharge destination except for two lesser quality trials
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      • 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.
      that provided evidence for improved activity performance 3 weeks following hip replacement (Table IIb).

       Effect of pre-operative exercise with education vs standard care for hip osteoarthritis

      Meta-analysis of two trials with 82 participants provided moderate quality evidence for improved Harris hip score 3 months following hip replacement (Fig. 5, Table V). Meta-analyses of two trials with 99 participants provided low quality evidence of a reduced number of days to first walk (Fig. 6), sit in a chair, use the toilet and climb stairs independently during the hospital stay following total hip replacement (Table V).
      Figure thumbnail gr5
      Fig. 5SMD (95% CI) of effect of pre-operative exercise and education vs standard care on Harris Hip Score at 12 weeks after total hip replacement.
      Figure thumbnail gr6
      Fig. 6SMD (95% CI) of effect of pre-operative exercise and education vs standard care on inpatient activity (number of days to first walking) after total hip replacement.
      Meta-analyses of two studies with 68 participants did not show any difference for pain before hip replacement (Table V). Meta-analyses of three studies with 127 participants did not show any difference for Harris hip score and hip abduction range of movement before hip replacement (Table V).
      A higher quality individual trial
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
      with outcomes not included in meta-analysis due to heterogeneity showed improved quality of life, hip abduction strength and external rotation range prior to hip replacement and reduced pain 12 weeks post-operatively (Table IIb). The one trial
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      which measured length of stay showed no difference (Table IIb).

       Effect of other pre-operative interventions vs standard care for knee or hip osteoarthritis

      Meta-analysis of two trials of acupuncture for knee osteoarthritis with 150 participants did not show any difference for timed 50 m walk prior to knee replacement (Table IV).
      Of other outcomes of trials not included in meta-analysis due to heterogeneity, a higher quality individual 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.
      of acupuncture for knee osteoarthritis showed improved Oxford knee score prior to knee replacement surgery and reduced pain 3 months after surgery. Self-management programs
      • Crotty M.
      • Prendergast J.
      • Battersby M.W.
      • Rowett D.
      • Graves S.E.
      • Leach G.
      • et al.
      Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial.
      • Nunez M.
      • Nunez E.
      • Segur J.M.
      • Mscule F.
      • Quinto L.
      • Hernandez M.V.
      • 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.
      demonstrated improved activity for knee osteoarthritis and improved quality of life for hip and knee osteoarthritis prior to surgery. A multidisciplinary pain management program
      • Berge D.J.
      • Dolin S.J.
      • Williams A.C.
      • Harman H.
      Pre-operative and post-operative effect of a pain management programme prior to total hip replacement: a randomized controlled trial.
      for hip osteoarthritis showed a large effect of reduced pain in the pre-operative period but not the post-operative period. A lesser quality small trial of electrical stimulation for knee osteoarthritis
      • Walls R.J.
      • McHugh G.
      • O’Gorman D.J.
      • Moyna N.N.M.
      • O’Byrne J.M.
      Effects of preoperative neuromuscular electrical stimulation on quadriceps strength and functional recovery in total knee arthroplasty. A pilot study.
      did not show an effect for any of the outcomes. Overall none of the other interventions showed any effect for post-operative outcomes including activity, health service utilisation and quality of life [Table IIa, Table IIb(a & b)].

       Effect of pre-operative interventions compared with another intervention

      None of the trials that compared one intervention with another showed any difference for measures of pain, musculoskeletal impairment, activity limitation, quality of life or health service utilisation (Table IIc).

      Discussion

       Summary of evidence

      The results of this systematic review provide low to moderate quality evidence that pre-operative interventions, particularly exercise, can have a modest effect prior to joint replacement surgery mainly by reducing pain for knee and hip osteoarthritis and improving activity for hip osteoarthritis. The results also provide low to moderate quality evidence that patients who completed exercise and education programs before hip replacement surgery may have improved function and activity in the short term after surgery. Despite these benefits, little post-operative benefit has been demonstrated for outcomes including pain, musculoskeletal impairment, activity performance for knee osteoarthritis, quality of life, length of stay and discharge destination.
      It may be argued that improved outcomes in the short term while waiting for surgery may be important for patients particularly when waiting times can exceed 1 year and were typically about 3 months in the current review. However, the value of these interventions is limited if they make minimal difference post-operatively. It is possible that marked reduction of pain that comes from replacing painful joint surfaces during surgery far outweighs modest contribution from pre-operative interventions. It is also possible that medical complications and hospital protocols are likely to have a major effect on health service utilisation (e.g., length of stay) that outweighs the effect of any pre-operative intervention.
      With the limited benefit for patients in the post-operative period, it could be considered that pre-operative interventions for osteoarthritis are not worthwhile, particularly for knee osteoarthritis. Although many trials evaluated post-operative outcomes, only three of the 23 included trials evaluated post-operative outcomes during the hospital stay. The current review provided some preliminary evidence from this small number of trials that the pre-operative programs may provide benefits during the hospital stay, suggesting this could be an area of further research. Also, a key benefit for patients not investigated in any of the trials may be an increased confidence in managing their condition to complete daily activities and increased confidence in their ability to cope with surgery. This outcome, a form of self-efficacy
      • Bandura A.
      Self-efficacy.
      has not been investigated in any of the trials in this review.
      There are also considerations about how feasible it is to implement a pre-operative intervention for people awaiting hip and knee replacement surgery. The results of this review showed that recruitment of patients for pre-operative interventions (especially group programs) can present difficulties for patients with end-stage osteoarthritis for reasons such as not wanting to travel each week for treatment, patients preferring to remain sedentary and wait for their operation, and patients dropping out for unrelated medical reasons. Currently, orthopaedic surgeons rarely prescribe pre-operative interventions because of limited known benefit on health outcomes post-operatively
      • 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.
      , a view supported by the findings of this review. Despite difficulties with recruitment, the results show good adherence to exercise interventions so once patients start they appear to be motivated to continue.
      Our findings are similar to a previous review
      • Ackerman I.N.
      • Bennell K.L.
      Does pre-operative physiotherapy improve outcomes from lower limb replacement surgery? A systematic review.
      but are not limited to a single discipline intervention, and include meta-analyses. Our review included eight trials published since the review by Coudeyre
      • 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.
      in 2007 and it also differed as they found that education intervention in a single trial
      • Siggeirsdottir K.
      • Olafsson O.
      • Jonsson H.
      • Iwarsson S.
      • Gudnason V.
      • Jonsson B.Y.
      Short hospital stay augmented with education and home-based rehabilitation improves function and quality of life after hip replacement.
      to be beneficial for health service utilisation (both length of stay and discharge destination). However, our review excluded this trial because it was not clear that the intervention included more than a single session.
      A strength of this systematic review is that it followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      The PRISMA group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      . Inclusion of only RCTs increases confidence in the results as findings would be expected to be less subject to bias. Applying the GRADE approach
      • GRADE Working Group
      Grading quality of evidence and strength of recommendations.
      to the questions that were answered with meta-analyses determines the level of confidence in the results for clinicians and policy makers.
      A limitation in this systematic review is that the search strategy did not include other languages and did not include all databases such as Cochrane Central Register of Controlled Trials. Nevertheless the strategy was comprehensive with only one additional article found by citation tracking. Only four of the 23 trials had 50 or more participants in each allocation arm. While small studies suffer from lack of power, they also often have a very select participant group (higher adherence that would be expected in the clinical situation), concentrated researcher attention resulting in a greater risk of inflated effect sizes
      • Hedges L.V.
      • Vevea J.L.
      Estimating effect size under publication bias: small sample properties and robustness of a random effects selection model.
      . There was an element of subjectivity in deciding if trials had sufficient clinical homogeneity to combine in meta-analyses; however, the process was conducted with careful consideration and the more conservative random effects model was used for analysis. Insufficient reporting meant that meta-analyses did not include all available trials. In fact most of the meta-analyses only involved two trials and only 10 of the 23 trials
      • Gilbey H.J.
      • Ackland T.R.
      • Tapper J.
      • Wang A.W.
      Perioperative exercise improves function following 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.
      • 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.
      • Christensen B.V.
      • Iuhl I.U.
      • Vilbek H.
      • Bulow H.
      • Dreijer N.C.
      • Rasmussen H.F.
      Acupuncture treatment of severe knee osteoarthrosis. A long-term 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.
      • Ferrara P.E.
      • Rabini A.
      • Aprile I.
      • Maggi L.
      • Piazzini D.B.
      • Logroscino G.
      • et al.
      Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip 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.
      • Vukomanovic A.
      • Popovic Z.
      • Durovic A.
      • Krstic L.
      The effects of short-term preoperative physical therapy and education on early functional recovery of patients younger than 70 undergoing total hip arthroplasty.
      • Rooks D.S.
      • Huang J.
      • Bierbaum B.E.
      • Bolus S.A.
      • Rubano J.
      • Connolly C.E.
      Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty.
      • 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.
      • 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.
      were used in the meta-analyses. A further limitation is that the quality of the evidence was rated high in only one meta-analysis. This reduces confidence in the findings. However, this might be more of a concern if the results of the review were more positive since it could be argued that lower quality evidence may be more subject to bias.

      Conclusion

      There is moderate quality evidence from four small RCTs that pre-operative exercise reduces pain prior to knee replacement. There is only low quality evidence from two small RCTs that pre-operative exercise reduces pain prior to hip replacement. There is moderate quality evidence from three small RCTs that pre-operative exercise improves activity prior to hip replacement. There is moderate quality evidence from two small RCTs that pre-operative exercise and education programs improve function 3 weeks after hip replacement. There is only low quality evidence from two small RCTs that pre-operative exercise combined with education programs improve activity during hospital stay after hip replacement. No evidence exists that pre-operative interventions reduce health service utilisation as represented by length of hospital stay or discharge destination. Further research is needed that focuses on post-operative outcomes during hospital stay.

      Authors’ contributions

      JAW designed the review, completed searches of databases and drafted the manuscript. NFT contributed to review design, data analysis and contributed to the writing of the paper by revising it critically for important intellectual content. Both authors read and approved the manuscript.

      Conflict of interest statement

      All authors declare that they do not have any potential conflict of interest.

      Competing interests

      None.

      Acknowledgements

      None.

      Appendix.

      Tabled 1Medline search strategy (n=748)
      Population
      S1. (MH “Osteoarthritis”) OR (MH “Osteoarthritis, Hip”) OR (MH “Osteoarthritis, Knee”) OR osteoarthr* S2. degenerate* S3. (MH “Arthritis”) OR arthritis S4. (MH “Knee”) OR knee OR (MH “Knee Joint”) S5. (MH “Hip”) OR hip OR (MH “Hip Joint”) S6. (MH “Lower Extremity”) OR lower limb
      S7=S1 OR S2 OR S3 OR S4 OR S5 OR S6
      S8. preadmission or pre admission or preoperat* or pre operat* or perioperat* or peri operat* S9. Pre surgery S10. prior or await* or wait* S11. (MH “Waiting Lists”) OR waiting list S12. (MH “Surgical Procedures, Elective”) OR elective surgical waiting list S13. End-stage
      S14=S8 OR S9 OR S10 or S11 OR S12 OR S13
      S15. (MH “Arthroplasty, Replacement”) OR (MH “Arthroplasty, Replacement, Hip”) OR (MH “Arthroplasty, Replacement, Knee”) OR joint replacement S16. “Surgical replacement” S17.(MH “Arthroplasty”) OR arthroplasty S18. (MH “Prostheses and Implants”) OR prosthes* S19. (MH “Knee Prosthesis”) OR knee prosthesis S20. (MH “Hip Prosthesis”) OR hip prosthesis S21. Total hip or total knee
      S22=S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21
      Intervention
      S24. (MH “Resistance Training”) OR strength training S25. (MH “Exercise”) OR (MH “Exercise Movement Techniques”) OR (MH “Exercise Therapy”) OR resist* exercise OR (MH “Muscle Stretching Exercises”) OR (MH “Motion Therapy, Continuous Passive”) S26. (MH “Rehabilitation”) OR rehabilitation S27. rehab* S28. (MH “Walking”) OR walking program* S29. MH “Musculoskeletal Manipulations”) OR manual therapy S30. balance exercise* or balance training S31. mobilisation or mobilization S32. kinetic chain S33. MH “ Physical Therapy (Specialty)”) OR (MH “Physical Therapy Modalities”) OR physiotherapy S34. physio* or physical therapy S35. (MH “Physical Therapy Department, Hospital”) OR physio* or physical therapy S36. (MH “Hydrotherapy”) OR hydrotherapy S37. pool based or aquatic therap* or aquatic exercis* S38. (MH “Home Care Services, Hospital-Based”) OR home based S39. (MH “Self Care”) OR self management S40. (MH “Disease Management”) OR arthritis self management S41. non surgical or non pharmacological or conservative management or conservative therap* S42. (MH “Self-Help Groups”) OR (MH “Self-Help Devices”) OR self help groups S43. “group program or group therap* S44. prehabilitation S45. (MH “Diet”) OR diet OR (MH “Diet, Fat-Restricted”) OR (MH “Diet, Reducing”) S46. (MH “Weight Loss”) OR weight los* S47. weight reduc* S48. (MH “Orthotic Devices”) OR orthotic devices S49. orthotic* or orthotists S50. (MH “Podiatry”) OR podiatry S51. (MH “Occupational Therapy”) OR occupational therapy S52. wedge or arch support* or insole* or shoe modif* S53. (MH “Tai Ji”) OR tai chi or ai chi S54. (MH “Cognitive Therapy”) OR cognitive behaviour* therapy OR (MH “Behavior Therapy”) S55. Cbt S56. counseling or psychology OR (MH “Psychology, Applied”) OR (MH “Psychological Techniques”) OR (MH “Psychology, Educational”) OR (MH “Psychology, Social”) S57. (MH “Counseling”) S58. functional restoration or pain program S59. taping or strapping S60. MH “canes” S61. walking aid or walking stick or ambulation aid S62. Pacing S63. (MH “Acupuncture”) OR acupuncture OR (MH “Acupuncture Therapy”) S64. Dry needling S65. heat* or thermotherapy S66. Massage therapy or MH “MH “Massage” S67. MH “Combined Modality Therapy”) OR multi modal physical therapy S68. (MH “Electric Stimulation Therapy”) OR (MH “Transcutaneous Electric Nerve Stimulation”) S69. electrotherap* S70. (MH “Allied Health Occupations”)
      S71=S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38 OR S39OR S40 OR S41 OR S42 OR S43 OR S44 OR S45 OR S46 OR S47 OR S48 OR S49 OR S50 OR S51 OR S52 OR S53 OR S54 OR S55 OR S56 OR S57 OR S58 OR S59 OR S60 OR S61 OR S62 OR S63 OR S64 OR S65 OR S66 OR S67 OR S68 OR S69 OR S70
      Design
      S72. (MH “Clinical Trial”) OR clinical trial OR (MH “Controlled Clinical Trial”) S73. (MH “Randomized Controlled Trials as Topic”) OR (MH “Randomized Controlled Trial”) OR randomised controlled trial or rct or randomized controlled trial S74. (MH “Case-Control Studies”) S75. (MH “Case-Control Studies”) OR (MH “Cohort Studies”) OR (MH “Cross-Sectional Studies”) OR (MH “Cross-Over Studies”) OR (MH “Prospective Studies”) OR (MH “Longitudinal Studies”) OR (MH “Intervention Studies”)
      S76=S72 OR S73 OR S74 OR S75
      S77=S7 and S14 and S22 and S71 and S76 (n=748)
      MH=medical subject heading (MeSH).

      References

        • Losina E.
        • Walensky R.P.
        • Kessler C.L.
        • Emrani P.S.
        • Reichmann W.M.
        • Wright E.A.
        • et al.
        Cost effectiveness of total knee arthroplasty in the United States patient risk and hospital volume.
        Arch Intern Med. 2009; 169: 1113-1121
        • Chang R.W.
        • Pellisier J.M.
        • Hazen G.B.
        A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip.
        JAMA. 1996; 275: 858-865
        • Hoogeboom T.J.
        • van den Ende C.H.M.
        • van der Sluis G.
        • Elings J.
        • Dronkers J.J.
        • Aiken A.B.
        • et al.
        The impact of waiting for total joint replacement on pain and functional status: a systematic review.
        Osteoarthritis Cartilage. 2009; 17: 1420-1427
        • Osborne R.
        • Haynes K.
        • Jones C.
        • Chubb P.
        • Robbins D.
        • Graves S.
        Orthopaedic Waiting List Project Summary Report Victorian Government.
        Department of Human Services, Melbourne2006 (pp. 7–9)
        • Australian Institute of Health and Welfare (AIHW)
        Australian Hospital Statistics 2003–04. AIHW Cat. No. HSE 37.
        AIHW, Canberra2005 (Health services series no. 23), pp. 109–126
      1. North East Local Health Integration Network: Integrated Health Service Plan.
        (Wait times. North Bay, Ontario)2006 (pp. 10–12)
        • Fielden J.M.
        • Cumming J.M.
        • Horne J.G.
        • Devane P.A.
        • Slack A.
        • Gallagher L.M.
        Waiting for hip arthroplasty: economic costs and outcomes.
        J Arthroplasty. 2005; 20: 990-997
        • Fransen M.
        • McConnell S.
        Land-based exercise for osteoarthritis of the knee: a meta-analysis of randomised controlled trials.
        J Rheumatol. 2009; 36: 1109-1117
        • Fransen M.
        • McConnell S.
        • Hernandez-Molina G.
        • Reichenbach S.
        Exercise for osteoarthritis of the hip.
        Cochrane Database Syst Rev. 2009; (Issue 3: Art. No.: CD007912. doi:10.1002/14651858.CD007912)
        • Ackerman I.N.
        • Bennell K.L.
        Does pre-operative physiotherapy improve outcomes from lower limb replacement surgery? A systematic review.
        Aust J Physiother. 2004; 50: 25-30
        • McDonald S.
        • Hetrick S.E.
        • Green S.
        Pre-operative education for hip or knee replacement.
        Cochrane Database Syst Rev. 2004; (Issue 1: Art. No.: CD003526. doi:10.1002/14651858.CD003526.pub2)
        • 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.
        Ann Readapt Med Phys. 2007; 50: 189-197
        • de Morton N.A.
        The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study.
        Aust J Physiother. 2009; 55: 129-133
        • Verhagen A.P.
        • de Vet H.C.
        • de Bie R.A.
        • Kessels A.G.
        • Boers M.
        • Bouter L.M.
        • et al.
        The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus.
        J Clin Epidemiol. 1998; 51: 1235-1241
        • Maher C.G.
        • Sherrington C.
        • Herbert R.D.
        • Moseley A.M.
        Reliability of the PEDro scale for rating quality of randomised controlled trials.
        Phys Ther. 2003; 83: 713-721
        • Hahne A.J.
        • Ford J.J.
        • McMeeken J.
        Conservative management of lumbar disc herniation with associated radiculopathy.
        Spine. 2010; 35: E488-E504
        • Maher C.G.
        A systematic review of workplace interventions to prevent low back pain.
        Aust J Physiother. 2000; 46: 259-269
      2. Centre for Evaluation and Monitoring, Durham University. Effect Size Calculator. http://www.cemcentre.org/evidence-based-education/effect-size-calculator.

        • Hozo S.
        • Djulbegovic B.
        • Hozo I.
        Estimating the mean and variance from the median, the range and the size of the sample.
        BMC Med Res Methodol. 2005; 5: 13https://doi.org/10.1186/1471-2288-5-13
        • Cohen J.
        Statistical Power Analysis for the Behavioural Sciences.
        2nd edn. Lawrence Erlbaum Associates, Hillsdale, NJ1988
        • Review Manager (RevMan)
        [Computer Program] Version 5.0.
        The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen2008
        • GRADE Working Group
        Grading quality of evidence and strength of recommendations.
        BMJ. 2004; 328: 1490https://doi.org/10.1136/bmj.328.7454.1490
        • Higgins J.P.T.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analysis.
        BMJ. 2003; 327: 557-560
        • Gilbey H.J.
        • Ackland T.R.
        • Tapper J.
        • Wang A.W.
        Perioperative exercise improves function following total hip arthroplasty: a randomized controlled trial.
        J Musculoskelet Res. 2003; 7: 111-123
        • 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.
        Clin Orthop Relat Res. 2003; 408: 193-200
        • 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.
        J Phys Ther Sci. 2009; 21: 113-119
        • Beaupre L.A.
        • Lier D.
        • Davies D.M.
        • Johnston D.B.C.
        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.
        J Rheumatol. 2004; 31: 1166-1173
        • Berge D.J.
        • Dolin S.J.
        • Williams A.C.
        • Harman H.
        Pre-operative and post-operative effect of a pain management programme prior to total hip replacement: a randomized controlled trial.
        Pain. 2004; 110: 33-39
        • Christensen B.V.
        • Iuhl I.U.
        • Vilbek H.
        • Bulow H.
        • Dreijer N.C.
        • Rasmussen H.F.
        Acupuncture treatment of severe knee osteoarthrosis. A long-term study.
        Acta Anaesthesiol Scand. 1992; 36: 519-525
        • Crotty M.
        • Prendergast J.
        • Battersby M.W.
        • Rowett D.
        • Graves S.E.
        • Leach G.
        • et al.
        Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial.
        Osteoarthritis Cartilage. 2009; 17: 1428-1433
        • 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.
        Clin Orthop Relat Res. 1996; 326: 174-182
        • Evgeniadis G.
        • Beneka A.
        • Malliou P.
        • Mavromoustakos S.
        • Godolias G.
        Effects of pre- or postoperative therapeutic exercise on the quality of life, before and after total knee arthroplasty for osteoarthritis.
        J Back Musculoskelet Rehabil. 2008; 21: 161-169
        • Ferrara P.E.
        • Rabini A.
        • Aprile I.
        • Maggi L.
        • Piazzini D.B.
        • Logroscino G.
        • et al.
        Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty.
        Clin Rehabil. 2008; 22: 977-986
        • 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.
        Clin Rehabil. 2004; 18: 353-358
        • Hoogeboom T.J.
        • Dronkers J.J.
        • van den Ende C.H.M.
        • Oosting E.
        • van Meeteren N.L.U.
        Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
        Clin Rehabil. 2010; https://doi.org/10.1177/0269215510371427
        • Nunez M.
        • Nunez E.
        • Segur J.M.
        • Mscule F.
        • Quinto L.
        • Hernandez M.V.
        • et al.