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The effect of preoperative training on functional recovery in patients undergoing total knee arthroplasty: A systematic review and meta-analysis
Accepted Manuscript The effect of preoperative training on functional recovery in patients undergoing total knee arthroplasty: A systematic review and meta-analysis Jian-xiong Ma, Lu-kai Zhang, Ming-jie Kuang, Jie Zhao, Ying Wang, Bin Lu, Lei Sun, Xin-long Ma PII:
S1743-9191(18)30493-X
DOI:
10.1016/j.ijsu.2018.01.015
Reference:
IJSU 4392
To appear in:
International Journal of Surgery
Received Date: 26 July 2017 Revised Date:
28 November 2017
Accepted Date: 3 January 2018
Please cite this article as: Ma J-x, Zhang L-k, Kuang M-j, Zhao J, Wang Y, Lu B, Sun L, Ma X-l, The effect of preoperative training on functional recovery in patients undergoing total knee arthroplasty: A systematic review and meta-analysis, International Journal of Surgery (2018), doi: 10.1016/ j.ijsu.2018.01.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The Effect of Preoperative Training on Functional Recovery in Patients Undergoing Total Knee Arthroplasty: A Systematic Review and Meta-Analysis
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Jian-xiong Ma, MD, PhD1,3, Lu-kai Zhang, MD1,2,3, Ming-jie Kuang, MD1,3, Jie Zhao,MD1,3,Ying Wang , MD1,3, Bin Lu, MD1,3, Lei Sun, MD1,3,Xin-long Ma, MD, PhD1,3* Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin, 300050，
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People’s Republic of China
Tianjin University of Traditional Chinese Medicine, 300193，People’s Republic of
China
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3 Tianjin Hospital, Tianjin University, Tianjin 300211, People’s Republic of China Corresponding author: Xin-long Ma, president of Tianjin Hospital, Tianjin, China, e-mail ： [email protected]. phone number: +86-15502269231, fax number: 022-23197199. Corresponding address: No. 155, Munan Road, Heping District, Tianjin, 300050, People's Republic of China.
Lu-kai Zhang Ming-jie Kuang Jie Zhao
[email protected] [email protected]
[email protected] [email protected] [email protected]
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Ying Wang
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Jian-xiong Ma
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Bin Lu
Lei Sun
Xin-long Ma
[email protected]
[email protected] [email protected]
* Co-author: The authors Jian-xiong Ma and Lu-kai Zhang and Ming-jie Kuang contributed equally to this work Acknowledgements: National Natural Science Foundation of China (NO. 11772226) Conflict of interest: The authors declare that they have no competing interests.
ACCEPTED MANUSCRIPT The Effect of Preoperative Training on Functional Recovery in Patients Undergoing Total
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Knee Arthroplasty: A Systematic Review and Meta-Analysis
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Abstract
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Objective: A meta-analysis to evaluate the efficacy of preoperative training on
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functional recovery in patients undergoing total knee arthroplasty.
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Method: Randomized controlled trials (RCTs) about relevant studies were searched
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from PubMed (1996-2017.4), Embase (1980-2017.4), and the Cochrane Library
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(CENTRAL 2017.4). Nine studies which evaluated the effect of preoperative training
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on functional recovery in patients undergoing TKA were included in our
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meta-analysis. Meta-analysis results were collected and analyzed by Review Manager
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5.3 (Copenhagen: The Nordic Cochrane Center the Collaboration 2014).
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Results: Nine studies containing 777 patients meet the inclusion criteria. Our pooled
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data analysis indicated that preoperative training was as effective as the control group
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in terms of visual analog scale(VAS) score at ascend stairs (P=0.41) and descend stars
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(P=0.80), rang of motion (ROM) of flexion (P=0.86) and extension (P=0.60), short
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form 36 (SF-36) of physical function score (P=0.07) and bodily pain score (P=0.39),
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western Ontario and Macmaster universities osteoarthritis index (WOMAC) function
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score (P=0.10), and time up and go (P=0.28). While differences were found in length
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of stay (P<0.05).
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Conclusions: Our meta-analysis demonstrated that preoperative training have the
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similar efficacy on functional recovery in patients following total knee arthroplasty
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compared with control group. However, high quality studies with more patients were
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needed in future.
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Keywords: Preoperative； Training； Total knee arthroplasty； Meta-analysis
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1. Introduction It was reported that the number of TKA procedures would reach at 3.48 million in
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United States when it comes to 2030[1]. At the end stage of osteoarthritis (OA), total
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knee arthroplasty (TKA) is the most important and effective method to relieve pain
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and improve functional recovery until now [2].
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One of most troublesome problems surgeons concern is postoperative functional
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recovery and pain following TKA [3-7]. Although most patients who undergoing TKA
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experienced pain-relief, approximately 30% of patients undergo significant pain and
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functional problem [8-10], and up to 15% patients suffers from different degrees of
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postoperative pain at 3~4 years [11].
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However, preoperative training was considered as an effective method in promoting
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postoperative functional recovery in past years [12-14]. A preoperative training
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program usually lasts 6 to 8 weeks before surgery mainly in order to increase
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quadriceps strength [15, 16]. It was reported that preoperative training program have
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effects on enhancing quadriceps strength which contribute to promote postoperative
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functional recovery and reduce pain [17]. A systematic review published 2012 draw a
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conclusion that compared with control group, preoperative training have an effect on
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reducing length of hospital stay while failed to find any beneficial effects on
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postoperative functional recovery[18]. Topp et al [12] reported that preoperative
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training group have effects on reduce visual analogue scale (VAS) score at ascend
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stairs and descend stairs. Similarly, Matassi et al [19]reported that the rehabilitation
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was shorter in preoperative training group compared to control group. These findings
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all demonstrated that preoperative training was beneficial significantly as
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exercised-based programs in relieving pain and accelerating functional performance
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among patients following total knee arthroplasty. However, the benefits of
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preoperative training are uncertain. Recently, a quantity of published studies failed to
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discover functional recovery improvements in patients after preoperative training
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[20-22]. A recently published study by Huber et al [20] even reported that
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preoperative training program have hampered potentially benefits effects on
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functional recovery. Until now, no consensus has been reached on the efficacy of preoperative training
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program following TKA [12, 23, 24]. Therefore, we made the first meta-analysis to
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investigate whether preoperative training leads to better postoperative functional
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recovery in patients following TKA.
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2. Material and method
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2.1 Search strategy
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Two reviewers systemically searched randomized controlled trials (RCTs) from
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electronic databases including PubMed (1996-2017.6), Embase (1980-2017.6), and
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the Cochrane Library (CENTRAL, 2017.6). Further articles were also discovered
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from related references. Only English publications were included in our meta-analysis.
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Thus, publication bias is unavoidable. “Total knee arthroplasty OR total knee
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replacement” and “Preoperative training OR preoperative exercise” were used as key
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words. The search results are presented in Fig.1.
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2.2 Inclusion criteria
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Trails were identified qualified for the meta-analysis on condition that they met the
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PICOS (participants, intervention, comparator, outcome, study design) criteria.
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1) Participants: patients undergoing primary TKA.
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2) Intervention: preoperative training.
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3) Comparison: placebo
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4) Outcomes: the primary outcomes included VAS score (ascend stairs and descend
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stairs), ROM (flexion and extension). Secondary outcomes included SF-36 score
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(physical functioning and pain), and WOMAC (functional score). Third outcomes included time up and go, and LOS.
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5) Study design: only RCTs were included.
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2.3 Data extraction
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Two reviewers extracted the data from included trials independently, and any
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disagreement between two reviewers was solved by third reviewer. Extracted data
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included authors, publication data, patients, age, gender, body mass index (BMI), 3
ACCEPTED MANUSCRIPT training duration, and preoperative diagnosis. Outcomes measures were extracted
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from each trial. The formula in Cochrane Handbook for Systematic Reviews of
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Interventions was used to calculate missing standard deviations.
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2.4 Quality assessment
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Two reviewers assessed the quality of included trials according to the rules of
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Cochrane Handbook 5.0.1. Following items were evaluated (all of the items were
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evaluated by “high risk”, “unclear risk”, and “low risk”):
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1) Random sequence generation
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2) Allocation concealment
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3) Blinding of participants and personnel
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4) Blinding of outcome assessment
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5) Incomplete outcome data
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6) Selective reporting
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7) Other bias
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2.5 Data analysis and statistical method
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Review Manager Software Windows 5.3 (Copenhagen: The Nordic Cochrane Center,
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the Collaboration, 2014) was used for the meta-analysis. For continuous outcomes, we
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used mean difference (MD) with 95% confidence intervals (CIs) to weigh the effect
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interval. For uncontinuous outcomes, odd ratio (OR) with 95% CIs was used to weigh
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the effect interval. Statistical heterogeneity between studies was assessed by the value
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of P and I2. We used a fixed-effects model when I2<50% and P>0.1, otherwise, a
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random-effects model was used for test.
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3.
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3.1 Search results
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A total of 135 studies were identifies through the search strategy. 62 studies were
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excluded by Endnote software. 60 studies were excluded by reading title and abstract.
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According to the inclusion criteria, 9 studies [12, 13, 17, 19-21, 24-26]were included
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Results
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ACCEPTED MANUSCRIPT by reading the full text. Among them, there were all RCTs. The demographic
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characteristics of included studies were summarized in table 1 and table 2.
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3.2 Risk of bias in included studies
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The risk of bias of included studies were presented in Fig.2 and Fig.3. All RCTs
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illustrated clear inclusion and exclusion criteria. Among the included trials, six studies
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[17, 19-21, 25, 26]reported that computer-generated numbers were used for random
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sequence generation and six studies[13, 17, 20, 21, 24, 26] declared allocation
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concealment by closed envelope or other methods, and the remaining studies did not
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report the random sequence generation or allocation concealment. The way of
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blinding of outcome assessment was not be reported in two studies [24, 25]. However,
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only one studies [13] illustrated the blinding method for participants and personnel.
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3.3 Meta-analysis results
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3.3.1 Visual analogue scale score
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Data from two studies including 125 knees reported the VAS scores at ascend stairs.
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No significant difference was found between two groups (MD=0.54; 95% CI, [-0.74,
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1.83]; P=0.41; Fig. 4). VAS score at descend stairs was shown in two studies
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containing 125 patients. Our results indicated that there were no significant
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differences between preoperative training and control groups (MD=0.20; 95% CI,
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[-1.37, 1.77]; P=0.80; Fig. 4). We used a random-effects model because significant
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heterogeneity was found in VAS score at ascend stairs(x2=84.53; df=1; P<0.05;
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I2=99%; Fig. 4) and descend stairs(x2=135.58; df=1; P<0.05; I2=99%; Fig .4).
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3.3.2 Range of motion
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ROM of extension was reported in three trials including342 patients. Due to the high
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heterogeneity between the trials (x2=272.82; df=3; P<0.05; I2=99%; Fig.5), a
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random-effects model was used. Our meta-analysis results showed that there were no
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significant differences between preoperative training group and control group
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(MD=-1.19; 95% CI, [-5.68, 3.31]; P=0.60; Fig.5). ROM of flexion at was shown in
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ACCEPTED MANUSCRIPT three studies containing 342 patients. No significant difference was found between
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preoperative training group and control group (MD=0.42; 95% CI, [-4.17, 5.00];
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P=0.86; Fig.5). There was significant heterogeneity (x2=62.25; df=3; P<0.05; I2=95%;
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Fig.5) in the meta-analysis, so we used a random-effects model.
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3.3.3 Short form-36 score
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Physical function score of SF-36 at 3 month was evaluated in 2 studies including a
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total of 176 patients. Our results indicated that there were no significant differences
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between the two groups (MD=-5.79; 95% CI, [-12.05, 0.47]; P=0.07; Fig.6). No
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heterogeneity was shown in our meta-analysis (x2=0.12; df=1; P=0.73; I2=0%; Fig.6),
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therefore, a fixed-effects model was applied.
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We extracted bodily pain score of SF-36 data from 3 studies involving 205 patients.
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No significant differences was found between preoperative training and control
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groups (MD=-2.21; 95% CI, [-7.22, 2.80]; P=0.39; Fig.6). A fixed-effects model was
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used for no heterogeneity was found between the two groups (x2=0.71; df=2; P=0.70;
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I2=0%; Fig.6).
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3.3.4 Macmaster universities osteoarthritis index score
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Function score of WOMAC was reported in 3 studies involved 111 patients. Pooled
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data indicated there were no significant differences between preoperative training and
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control group (MD=-6.25; 95% CI, [-13.76, 1.16]; P=0.10; Fig.7). A random-effects
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model was used for statistical heterogeneity through the meta-analysis(x2=13.19; df=2;
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P<0.05; I2=85%; Fig.7).
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3.3.5 Time up and go
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The time up and go test was performed in 2 studies containing 74 patients. No
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significant differences were discovered between the 2 groups (MD=-1.05; 95% CI,
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[-2.97, 0.87]; P=0.28; Fig.8). A fixed-effects model was applied due to the low
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statistical heterogeneity (x2=0.47; df=1; P=0.49; I2=0%; Fig.8).
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3.3.6 Length of stay
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We extracted length of stay data from 4 studies including 540 patients. Differences
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was found between preoperative training and control groups (MD= -1.27; 95% CI,
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[-1.82, -0.71]; P<0.05; Fig.9). A random-effects model was used, because significant
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heterogeneity was shown in our meta-analysis(x2=7.45; df=3; P=0.06; I2=60%; Fig.9).
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Discussion While preoperative training has been widely applied for patients prepared for TKA,
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the efficacy is still controversial [17, 20]. A previous systematic review[18] about
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preoperative training was conducted, and its results showed similar outcomes in
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effects on functional recovery between two groups. Recently, the preoperative training
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program has been gained wide attention, for large quantity of literature fails in
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conducting clear functional recovery improvements after preoperative training
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program [20, 21]. To evaluate the efficacy of preoperative training program, we
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conducted the meta-analysis. A total of nine randomized controlled trials (RCTs) with
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777 patients were included in our meta-analysis. our pooled data of current study
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indicated that preoperative training did not have superior efficacy on range of motion,
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visual analogue scale score, WOMAC function score, SF-36 physical function score,
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bodily pain score, and time up and go. Interestingly, the preoperative training group
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showed an advantage in LOS over control group. While Rooks et al [13]reported that
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there were no significant reduction in preoperative training group, similar finds were
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indicated by Beaupre et al [21]. Patients usually discharged home at 5 to 7days
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postoperatively. Functional recovery and knee ROM are not considerations for
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remaining in hospital, for all patients received further physical therapy upon discharge
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and all length of hospital including transfer length of hospital stay and readmission
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length of hospital stay was taken into account[21].
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VAS score was the primary outcome assessed in our meta-analysis. Our results
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showed that preoperative training was as effective for postoperative pain-relief as
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control group. Meanwhile, risk of bias and high heterogeneity should be taken into
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consideration when interpreting the results. Several studies have reported that
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preoperative training group significantly improved pain relief after TKA compared to
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control group [12, 26]. A prospective study conducted by Topp et al [12]showed that
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postoperative VAS scores were much lower in patients treated with preoperative
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training program following TKA. Although these studies showed positive results of
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preoperative training, poor study design and low simple size of studies decreased the 7
ACCEPTED MANUSCRIPT degree of evidence. Recently, some randomized controlled studies of high-quality
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reported that preoperative training group have the similar effects after TKA on VAS
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score compared to control group[20, 24]. This was consistent with our findings. In our
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meta-analysis, no significant differences were found between preoperative training
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group and control group. Swank et al [24]demonstrated that preoperative training
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group even have high VAS scores at ascend and descend stairs compared to control
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group. Therefore, compared with control group, preoperative training group provided
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equally effective functional recovery for patients following TKA.
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The knee range of motion was also an important indicator for evaluating the
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functional recovery effects of preoperative training [17]. It was discovered that early
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mobilization facilitate functional recovery effectively. An RCT made by Calatayud et
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al [17] illustrated that preoperative training group earned higher ROM compared with
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control group. However, several studies published recently reported that there were no
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statistically significant differences between the two groups [19-21]. Matassi et al [19]
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also demonstrated that preoperative training group did not show significant
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improvement on knee ROM. The results of our meta-analysis are in consensus with
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these finds above. Our meta-analysis showed that TKA patients had similar knee
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ROM in both preoperative training and control group.
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Macmaster universities osteoarthritis index (WOMAC) score and short-form 36
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(SF-36) score were used to assess the functional recovery following TKA. Calatayud
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et al [17]reported that no improvement for WOMAC function score was found in
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preoperative training group. Similarly, Rooks et al [13]demonstrated that SF-36
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bodily pain score and WOMAC function score were not different between
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preoperative training and control groups. Huber et al[20] also declared no differences
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were showed in SF-36 physical function score in both preoperative training and
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control groups at three month postoperatively. As for test for time up and go, Huber et
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al [20]failed to find any difference in both groups. Similar finds were reported by
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Rooks et al [13]. Taking these findings together, we made conclusion that
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preoperative training group achieved similar effects for the SF-36 score at bodily pain
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and physical function, WOMAC function score, and time up and go test compared to
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ACCEPTED MANUSCRIPT control group in patients undergoing TKA. Thurs our pooled data indicated that it was
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not suitable for patients who undergoing TKA to receive preoperative training. While
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we should take the limited number of patients in to consideration when interrupting
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the findings, as well as the intensity and duration of training may also impact the
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outcomes. What is more, our meta-analysis indicated that preoperative training
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regimen correlates with reduction in length of hospital stay. Thus, we intend to find
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whether shorter preoperative training makes a difference in functional recovery for
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patients undergoing TKA for shorter preoperative exercise regimens are employed.
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Our systematic review and meta-analysis has several limitations: (1) Only nine
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RCTs were included in our meta-analysis, and the sample size of each study was
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small, which lowed the statistical power of our meta-analysis. (2) Only English
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publications were included in our meta-analysis. Thus, publication bias is unavoidable.
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(3) Outcomes such as knee society score, complications, and cost were not analyzed
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due to insufficient data. (4) Due to the significant heterogeneity of ROM at flexion (I2
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= 95%) and extension (I2 = 99%), we try to investigated the source of heterogeneity.
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When we did not include the study of Calatayud et al [17], the heterogeneity of ROM
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at flexion (95%CI,-2.65 to -0.30, I2 = 0%) and extension (95%CI,-0.23 to 1.13, I2 =
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0%) decreased significantly. Therefore we believe that the study was the source of
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heterogeneity. In the study of Calatayud et al [17], the preoperative training group
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completed a training programme prior to surgery for 8 weeks which is longer than
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other studies. Therefore, the duration of preoperative training may be a source of
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heterogeneity. Meta-analysis (PRISMA) guidelines and Cochrane Handbook were
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used to evaluate the quality of extract data in all included studies to ensure our
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meta-analysis results reliable and veritable.
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5. Conclusion
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Compared with control group, preoperative training group shows similar effects on
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function recovery after TKA, which indicated that too much training has no role in the
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preoperative period. What is more, because too much preoperative training is costly
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and time-consuming, we recommended that preoperative training is not worthy of
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being applied for patients. 9
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Figure captions:
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Figure.1: The search results and selection procedure.
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Figure.2: The risk of bias summary of the included studies.
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Figure.3: The risk of bias graph of the included studies.
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Figure.4: A forest plot diagram showing the VAS score.
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Figure.5: A forest plot diagram showing the ROM.
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Figure.6: A forest plot diagram showing the SF-36 score.
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Figure.7: A forest plot diagram showing the WOMAC score.
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Figure.8: A forest plot diagram showing the time up and go.
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Figure.9: A forest plot diagram showing the LOS.
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Credit: All figures can be printed by international journal of surgery@.
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Table 1: The characteristics of included studies Preoperative Training Group/Control group Female Patients(n)
Ages(y)
Gender (%)
Huber et al 2015 [20] Matassi et al 2014 [19] Huang et al 2012 [26] Gstoettner et
22/22
66.7/66.8
N/A
22/23
68.8/71.9
50/43.5
61/61
66/67
54.1/42.6
126/117
69.8/70.5
69.8/73.5
18/20
al 2011 [25] Swank et al
36/35
2011 [24] Topp 2009 et al [12]
26/28
Rooks et al Beaupre et al 2004 [21]
Preoperative
Type
Diagnosis
RCT
OA
30.8/29.9
RCT
OA
29/28
RCT
OA
27.1/27.2
RCT
OA
72.8/66.9
88.9/70
27.4/28.2
RCT
OA
63.1/62.6
66.7/62.9
35.9/32.9
RCT
OA
64.1/63.5
73/64
32.2/32
RCT
OA
RCT
OA
RCT
OA
14/15
67/68
65/66
67/67
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31/32
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BMI(kg/m )
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N/A
60/50
34.7/32.7 32/31
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of Weeks
Number of
Training Programme
Pneumatic
Surgical
Times/Week
(pre-training group)
Tourniquet
Approach
Surgery
extension, leg curl, and Calatayud et al 2016 [17]
8
3
hip abduction (5 sets of 10 repetitions for each exercise, with 60s rest between sets)
Huber et al 2015 [20]
4~12
N/A
Use
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Seated leg press, knee
programme-total joint replacement
N/A
(NEMEX-TJR)[27]
N/A
medial
parapatellar arthrotomy
primary TKA
primary TKA
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(sustained for 30s and repeated for 4 times,
with 10s rest between stretches):
2014 [19]
6
5
Standardized
and hamstring
surgical
stretching. Muscle
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quadriceps stretching,
N/A
technique
training: isometric
with patellar
quadriceps, isotonic
resurfacing
primary TKA
hamstring, isotonic
quadriceps contraction
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held in mid-flexion for
Huang et al 2012 [26]
4
5s, and dynamic stepping exercise. Muscle strength training: knee setting, 7
ankle pumping, and hip
N/A
N/A
N/A
N/A
abduction with
primary TKA
resistance Home training consisting of warming
Gstoettner et al 2011 [25]
6
N/A
up by walking, stretching and the proprioceptive training exercise learnt
1
primary TKA
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[12]
Rooks et al 2006
6
3
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During first 3 weeks, single-joint movement while standing in chest-deep water (1~2 sets×8~12reptitions). During weeks 4~6, a total body fitness program of cardiovascular, strength, and flexibility training. Education program: crutch walking on level ground and on stairs, bed mobility and transfers, and the postoperative ROM routine. Exercise program: simple strengthening exercise with progressive resistance, warmup and cool-down
3
2
N/A
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N/A
Resistance training, flexibility, and step training
N/A
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Topp et al 2009
3
N/A
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Exercise programme(1or 2 sets×10repeats): warm-up(5-min walking), leg extension, leg curl, hip abduction, hip flexion, hip extension, foot plantar flexion, foot dorsiflexion, step ups-forward/lateral both sides, and cool down
standard anterior surgical approach
N/A
N/A
N/A
N/A
primary TKA
primary TKA
primary TKA
primary TKA
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N/A, not applicable; TKA, total knee arthroplasty; ROM, range of motion
3
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1. We made this meta-analysis to evaluate the efficacy of preoperative training programme on functional recovery in early post-operative periods after TKA. 2. Preoperative training will not improve the ROM in patients received TKA. 3. Preoperative training have the similar efficacy on functional recovery in patients following TKA compared with control group.
S1743-9191(18)30493-X
DOI:
10.1016/j.ijsu.2018.01.015
Reference:
IJSU 4392
To appear in:
International Journal of Surgery
Received Date: 26 July 2017 Revised Date:
28 November 2017
Accepted Date: 3 January 2018
Please cite this article as: Ma J-x, Zhang L-k, Kuang M-j, Zhao J, Wang Y, Lu B, Sun L, Ma X-l, The effect of preoperative training on functional recovery in patients undergoing total knee arthroplasty: A systematic review and meta-analysis, International Journal of Surgery (2018), doi: 10.1016/ j.ijsu.2018.01.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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The Effect of Preoperative Training on Functional Recovery in Patients Undergoing Total Knee Arthroplasty: A Systematic Review and Meta-Analysis
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Jian-xiong Ma, MD, PhD1,3, Lu-kai Zhang, MD1,2,3, Ming-jie Kuang, MD1,3, Jie Zhao,MD1,3,Ying Wang , MD1,3, Bin Lu, MD1,3, Lei Sun, MD1,3,Xin-long Ma, MD, PhD1,3* Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin, 300050，
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People’s Republic of China
Tianjin University of Traditional Chinese Medicine, 300193，People’s Republic of
China
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3 Tianjin Hospital, Tianjin University, Tianjin 300211, People’s Republic of China Corresponding author: Xin-long Ma, president of Tianjin Hospital, Tianjin, China, e-mail ： [email protected]. phone number: +86-15502269231, fax number: 022-23197199. Corresponding address: No. 155, Munan Road, Heping District, Tianjin, 300050, People's Republic of China.
Lu-kai Zhang Ming-jie Kuang Jie Zhao
[email protected] [email protected]
[email protected] [email protected] [email protected]
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Bin Lu
Lei Sun
Xin-long Ma
[email protected]
[email protected] [email protected]
* Co-author: The authors Jian-xiong Ma and Lu-kai Zhang and Ming-jie Kuang contributed equally to this work Acknowledgements: National Natural Science Foundation of China (NO. 11772226) Conflict of interest: The authors declare that they have no competing interests.
ACCEPTED MANUSCRIPT The Effect of Preoperative Training on Functional Recovery in Patients Undergoing Total
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Knee Arthroplasty: A Systematic Review and Meta-Analysis
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Abstract
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Objective: A meta-analysis to evaluate the efficacy of preoperative training on
5
functional recovery in patients undergoing total knee arthroplasty.
6
Method: Randomized controlled trials (RCTs) about relevant studies were searched
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from PubMed (1996-2017.4), Embase (1980-2017.4), and the Cochrane Library
8
(CENTRAL 2017.4). Nine studies which evaluated the effect of preoperative training
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on functional recovery in patients undergoing TKA were included in our
10
meta-analysis. Meta-analysis results were collected and analyzed by Review Manager
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5.3 (Copenhagen: The Nordic Cochrane Center the Collaboration 2014).
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Results: Nine studies containing 777 patients meet the inclusion criteria. Our pooled
13
data analysis indicated that preoperative training was as effective as the control group
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in terms of visual analog scale(VAS) score at ascend stairs (P=0.41) and descend stars
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(P=0.80), rang of motion (ROM) of flexion (P=0.86) and extension (P=0.60), short
16
form 36 (SF-36) of physical function score (P=0.07) and bodily pain score (P=0.39),
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western Ontario and Macmaster universities osteoarthritis index (WOMAC) function
18
score (P=0.10), and time up and go (P=0.28). While differences were found in length
19
of stay (P<0.05).
20
Conclusions: Our meta-analysis demonstrated that preoperative training have the
21
similar efficacy on functional recovery in patients following total knee arthroplasty
22
compared with control group. However, high quality studies with more patients were
23
needed in future.
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Keywords: Preoperative； Training； Total knee arthroplasty； Meta-analysis
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1. Introduction It was reported that the number of TKA procedures would reach at 3.48 million in
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United States when it comes to 2030[1]. At the end stage of osteoarthritis (OA), total
5
knee arthroplasty (TKA) is the most important and effective method to relieve pain
6
and improve functional recovery until now [2].
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One of most troublesome problems surgeons concern is postoperative functional
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recovery and pain following TKA [3-7]. Although most patients who undergoing TKA
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experienced pain-relief, approximately 30% of patients undergo significant pain and
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functional problem [8-10], and up to 15% patients suffers from different degrees of
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postoperative pain at 3~4 years [11].
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However, preoperative training was considered as an effective method in promoting
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postoperative functional recovery in past years [12-14]. A preoperative training
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program usually lasts 6 to 8 weeks before surgery mainly in order to increase
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quadriceps strength [15, 16]. It was reported that preoperative training program have
16
effects on enhancing quadriceps strength which contribute to promote postoperative
17
functional recovery and reduce pain [17]. A systematic review published 2012 draw a
18
conclusion that compared with control group, preoperative training have an effect on
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reducing length of hospital stay while failed to find any beneficial effects on
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postoperative functional recovery[18]. Topp et al [12] reported that preoperative
21
training group have effects on reduce visual analogue scale (VAS) score at ascend
22
stairs and descend stairs. Similarly, Matassi et al [19]reported that the rehabilitation
23
was shorter in preoperative training group compared to control group. These findings
24
all demonstrated that preoperative training was beneficial significantly as
25
exercised-based programs in relieving pain and accelerating functional performance
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among patients following total knee arthroplasty. However, the benefits of
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preoperative training are uncertain. Recently, a quantity of published studies failed to
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discover functional recovery improvements in patients after preoperative training
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[20-22]. A recently published study by Huber et al [20] even reported that
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preoperative training program have hampered potentially benefits effects on
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functional recovery. Until now, no consensus has been reached on the efficacy of preoperative training
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program following TKA [12, 23, 24]. Therefore, we made the first meta-analysis to
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investigate whether preoperative training leads to better postoperative functional
5
recovery in patients following TKA.
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2. Material and method
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2.1 Search strategy
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Two reviewers systemically searched randomized controlled trials (RCTs) from
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electronic databases including PubMed (1996-2017.6), Embase (1980-2017.6), and
11
the Cochrane Library (CENTRAL, 2017.6). Further articles were also discovered
12
from related references. Only English publications were included in our meta-analysis.
13
Thus, publication bias is unavoidable. “Total knee arthroplasty OR total knee
14
replacement” and “Preoperative training OR preoperative exercise” were used as key
15
words. The search results are presented in Fig.1.
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2.2 Inclusion criteria
17
Trails were identified qualified for the meta-analysis on condition that they met the
18
PICOS (participants, intervention, comparator, outcome, study design) criteria.
19
1) Participants: patients undergoing primary TKA.
20
2) Intervention: preoperative training.
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3) Comparison: placebo
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4) Outcomes: the primary outcomes included VAS score (ascend stairs and descend
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stairs), ROM (flexion and extension). Secondary outcomes included SF-36 score
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(physical functioning and pain), and WOMAC (functional score). Third outcomes included time up and go, and LOS.
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5) Study design: only RCTs were included.
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2.3 Data extraction
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Two reviewers extracted the data from included trials independently, and any
29
disagreement between two reviewers was solved by third reviewer. Extracted data
30
included authors, publication data, patients, age, gender, body mass index (BMI), 3
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2
from each trial. The formula in Cochrane Handbook for Systematic Reviews of
3
Interventions was used to calculate missing standard deviations.
4
2.4 Quality assessment
5
Two reviewers assessed the quality of included trials according to the rules of
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Cochrane Handbook 5.0.1. Following items were evaluated (all of the items were
7
evaluated by “high risk”, “unclear risk”, and “low risk”):
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1) Random sequence generation
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2) Allocation concealment
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3) Blinding of participants and personnel
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4) Blinding of outcome assessment
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5) Incomplete outcome data
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6) Selective reporting
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7) Other bias
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2.5 Data analysis and statistical method
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Review Manager Software Windows 5.3 (Copenhagen: The Nordic Cochrane Center,
17
the Collaboration, 2014) was used for the meta-analysis. For continuous outcomes, we
18
used mean difference (MD) with 95% confidence intervals (CIs) to weigh the effect
19
interval. For uncontinuous outcomes, odd ratio (OR) with 95% CIs was used to weigh
20
the effect interval. Statistical heterogeneity between studies was assessed by the value
21
of P and I2. We used a fixed-effects model when I2<50% and P>0.1, otherwise, a
22
random-effects model was used for test.
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3.
24
3.1 Search results
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A total of 135 studies were identifies through the search strategy. 62 studies were
26
excluded by Endnote software. 60 studies were excluded by reading title and abstract.
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According to the inclusion criteria, 9 studies [12, 13, 17, 19-21, 24-26]were included
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Results
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2
characteristics of included studies were summarized in table 1 and table 2.
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3.2 Risk of bias in included studies
4
The risk of bias of included studies were presented in Fig.2 and Fig.3. All RCTs
5
illustrated clear inclusion and exclusion criteria. Among the included trials, six studies
6
[17, 19-21, 25, 26]reported that computer-generated numbers were used for random
7
sequence generation and six studies[13, 17, 20, 21, 24, 26] declared allocation
8
concealment by closed envelope or other methods, and the remaining studies did not
9
report the random sequence generation or allocation concealment. The way of
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blinding of outcome assessment was not be reported in two studies [24, 25]. However,
11
only one studies [13] illustrated the blinding method for participants and personnel.
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3.3 Meta-analysis results
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3.3.1 Visual analogue scale score
14
Data from two studies including 125 knees reported the VAS scores at ascend stairs.
15
No significant difference was found between two groups (MD=0.54; 95% CI, [-0.74,
16
1.83]; P=0.41; Fig. 4). VAS score at descend stairs was shown in two studies
17
containing 125 patients. Our results indicated that there were no significant
18
differences between preoperative training and control groups (MD=0.20; 95% CI,
19
[-1.37, 1.77]; P=0.80; Fig. 4). We used a random-effects model because significant
20
heterogeneity was found in VAS score at ascend stairs(x2=84.53; df=1; P<0.05;
21
I2=99%; Fig. 4) and descend stairs(x2=135.58; df=1; P<0.05; I2=99%; Fig .4).
22
3.3.2 Range of motion
23
ROM of extension was reported in three trials including342 patients. Due to the high
24
heterogeneity between the trials (x2=272.82; df=3; P<0.05; I2=99%; Fig.5), a
25
random-effects model was used. Our meta-analysis results showed that there were no
26
significant differences between preoperative training group and control group
27
(MD=-1.19; 95% CI, [-5.68, 3.31]; P=0.60; Fig.5). ROM of flexion at was shown in
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preoperative training group and control group (MD=0.42; 95% CI, [-4.17, 5.00];
3
P=0.86; Fig.5). There was significant heterogeneity (x2=62.25; df=3; P<0.05; I2=95%;
4
Fig.5) in the meta-analysis, so we used a random-effects model.
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3.3.3 Short form-36 score
6
Physical function score of SF-36 at 3 month was evaluated in 2 studies including a
7
total of 176 patients. Our results indicated that there were no significant differences
8
between the two groups (MD=-5.79; 95% CI, [-12.05, 0.47]; P=0.07; Fig.6). No
9
heterogeneity was shown in our meta-analysis (x2=0.12; df=1; P=0.73; I2=0%; Fig.6),
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therefore, a fixed-effects model was applied.
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We extracted bodily pain score of SF-36 data from 3 studies involving 205 patients.
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No significant differences was found between preoperative training and control
13
groups (MD=-2.21; 95% CI, [-7.22, 2.80]; P=0.39; Fig.6). A fixed-effects model was
14
used for no heterogeneity was found between the two groups (x2=0.71; df=2; P=0.70;
15
I2=0%; Fig.6).
16
3.3.4 Macmaster universities osteoarthritis index score
17
Function score of WOMAC was reported in 3 studies involved 111 patients. Pooled
18
data indicated there were no significant differences between preoperative training and
19
control group (MD=-6.25; 95% CI, [-13.76, 1.16]; P=0.10; Fig.7). A random-effects
20
model was used for statistical heterogeneity through the meta-analysis(x2=13.19; df=2;
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P<0.05; I2=85%; Fig.7).
22
3.3.5 Time up and go
23
The time up and go test was performed in 2 studies containing 74 patients. No
24
significant differences were discovered between the 2 groups (MD=-1.05; 95% CI,
25
[-2.97, 0.87]; P=0.28; Fig.8). A fixed-effects model was applied due to the low
26
statistical heterogeneity (x2=0.47; df=1; P=0.49; I2=0%; Fig.8).
27
3.3.6 Length of stay
28
We extracted length of stay data from 4 studies including 540 patients. Differences
29
was found between preoperative training and control groups (MD= -1.27; 95% CI,
30
[-1.82, -0.71]; P<0.05; Fig.9). A random-effects model was used, because significant
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heterogeneity was shown in our meta-analysis(x2=7.45; df=3; P=0.06; I2=60%; Fig.9).
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4.
Discussion While preoperative training has been widely applied for patients prepared for TKA,
4
the efficacy is still controversial [17, 20]. A previous systematic review[18] about
5
preoperative training was conducted, and its results showed similar outcomes in
6
effects on functional recovery between two groups. Recently, the preoperative training
7
program has been gained wide attention, for large quantity of literature fails in
8
conducting clear functional recovery improvements after preoperative training
9
program [20, 21]. To evaluate the efficacy of preoperative training program, we
10
conducted the meta-analysis. A total of nine randomized controlled trials (RCTs) with
11
777 patients were included in our meta-analysis. our pooled data of current study
12
indicated that preoperative training did not have superior efficacy on range of motion,
13
visual analogue scale score, WOMAC function score, SF-36 physical function score,
14
bodily pain score, and time up and go. Interestingly, the preoperative training group
15
showed an advantage in LOS over control group. While Rooks et al [13]reported that
16
there were no significant reduction in preoperative training group, similar finds were
17
indicated by Beaupre et al [21]. Patients usually discharged home at 5 to 7days
18
postoperatively. Functional recovery and knee ROM are not considerations for
19
remaining in hospital, for all patients received further physical therapy upon discharge
20
and all length of hospital including transfer length of hospital stay and readmission
21
length of hospital stay was taken into account[21].
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VAS score was the primary outcome assessed in our meta-analysis. Our results
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showed that preoperative training was as effective for postoperative pain-relief as
24
control group. Meanwhile, risk of bias and high heterogeneity should be taken into
25
consideration when interpreting the results. Several studies have reported that
26
preoperative training group significantly improved pain relief after TKA compared to
27
control group [12, 26]. A prospective study conducted by Topp et al [12]showed that
28
postoperative VAS scores were much lower in patients treated with preoperative
29
training program following TKA. Although these studies showed positive results of
30
preoperative training, poor study design and low simple size of studies decreased the 7
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2
reported that preoperative training group have the similar effects after TKA on VAS
3
score compared to control group[20, 24]. This was consistent with our findings. In our
4
meta-analysis, no significant differences were found between preoperative training
5
group and control group. Swank et al [24]demonstrated that preoperative training
6
group even have high VAS scores at ascend and descend stairs compared to control
7
group. Therefore, compared with control group, preoperative training group provided
8
equally effective functional recovery for patients following TKA.
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The knee range of motion was also an important indicator for evaluating the
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functional recovery effects of preoperative training [17]. It was discovered that early
11
mobilization facilitate functional recovery effectively. An RCT made by Calatayud et
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al [17] illustrated that preoperative training group earned higher ROM compared with
13
control group. However, several studies published recently reported that there were no
14
statistically significant differences between the two groups [19-21]. Matassi et al [19]
15
also demonstrated that preoperative training group did not show significant
16
improvement on knee ROM. The results of our meta-analysis are in consensus with
17
these finds above. Our meta-analysis showed that TKA patients had similar knee
18
ROM in both preoperative training and control group.
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Macmaster universities osteoarthritis index (WOMAC) score and short-form 36
20
(SF-36) score were used to assess the functional recovery following TKA. Calatayud
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et al [17]reported that no improvement for WOMAC function score was found in
22
preoperative training group. Similarly, Rooks et al [13]demonstrated that SF-36
23
bodily pain score and WOMAC function score were not different between
24
preoperative training and control groups. Huber et al[20] also declared no differences
25
were showed in SF-36 physical function score in both preoperative training and
26
control groups at three month postoperatively. As for test for time up and go, Huber et
27
al [20]failed to find any difference in both groups. Similar finds were reported by
28
Rooks et al [13]. Taking these findings together, we made conclusion that
29
preoperative training group achieved similar effects for the SF-36 score at bodily pain
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and physical function, WOMAC function score, and time up and go test compared to
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2
not suitable for patients who undergoing TKA to receive preoperative training. While
3
we should take the limited number of patients in to consideration when interrupting
4
the findings, as well as the intensity and duration of training may also impact the
5
outcomes. What is more, our meta-analysis indicated that preoperative training
6
regimen correlates with reduction in length of hospital stay. Thus, we intend to find
7
whether shorter preoperative training makes a difference in functional recovery for
8
patients undergoing TKA for shorter preoperative exercise regimens are employed.
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Our systematic review and meta-analysis has several limitations: (1) Only nine
10
RCTs were included in our meta-analysis, and the sample size of each study was
11
small, which lowed the statistical power of our meta-analysis. (2) Only English
12
publications were included in our meta-analysis. Thus, publication bias is unavoidable.
13
(3) Outcomes such as knee society score, complications, and cost were not analyzed
14
due to insufficient data. (4) Due to the significant heterogeneity of ROM at flexion (I2
15
= 95%) and extension (I2 = 99%), we try to investigated the source of heterogeneity.
16
When we did not include the study of Calatayud et al [17], the heterogeneity of ROM
17
at flexion (95%CI,-2.65 to -0.30, I2 = 0%) and extension (95%CI,-0.23 to 1.13, I2 =
18
0%) decreased significantly. Therefore we believe that the study was the source of
19
heterogeneity. In the study of Calatayud et al [17], the preoperative training group
20
completed a training programme prior to surgery for 8 weeks which is longer than
21
other studies. Therefore, the duration of preoperative training may be a source of
22
heterogeneity. Meta-analysis (PRISMA) guidelines and Cochrane Handbook were
23
used to evaluate the quality of extract data in all included studies to ensure our
24
meta-analysis results reliable and veritable.
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5. Conclusion
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Compared with control group, preoperative training group shows similar effects on
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function recovery after TKA, which indicated that too much training has no role in the
28
preoperative period. What is more, because too much preoperative training is costly
29
and time-consuming, we recommended that preoperative training is not worthy of
30
being applied for patients. 9
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Kurtz, S., et al., Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am, 2007. 89(4): p. 780-5. Carr, A.J., et al., Knee replacement. Lancet, 2012. 379(9823): p. 1331-40.
3.
Palmer, K.T., The older worker with osteoarthritis of the knee. Br Med Bull, 2012. 102: p.
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79-88. 4.
Jones, C.A., et al., Health related quality of life outcomes after total hip and knee arthroplasties in a community based population. J Rheumatol, 2000. 27(7): p. 1745-52.
5.
Allen, K.D. and Y.M. Golightly, State of the evidence. Curr Opin Rheumatol, 2015. 27(3): p. 276-83.
Meneghini, R.M., G.S. Russo, and J.R. Lieberman, Modern perceptions and expectations
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regarding total knee arthroplasty. J Knee Surg, 2014. 27(2): p. 93-7. 7.
Hamilton, D.F., et al., Do modern total knee replacements offer better value for money? A
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health economic analysis. Int Orthop, 2013. 37(11): p. 2147-52.
Alzahrani, K., et al., Prevalence of clinically significant improvement following total knee replacement. J Rheumatol, 2011. 38(4): p. 753-9.
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Duchman, K.R., Y. Gao, and P. Phisitkul, Effects of total knee and hip arthroplasty on body weight. Orthopedics, 2014. 37(3): p. e278-85.
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Razmjou, H., et al., Traditional assessment of health outcome following total knee arthroplasty was confounded by response shift phenomenon. J Clin Epidemiol, 2009. 62(1): p.
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Wylde, V., et al., Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain, 2011. 152(3): p. 566-72.
12.
Topp, R., et al., The effect of prehabilitation exercise on strength and functioning after total
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Rooks, D.S., et al., Effect of preoperative exercise on measures of functional status in men and
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knee arthroplasty. Pm r, 2009. 1(8): p. 729-35. women undergoing total hip and knee arthroplasty. Arthritis Rheum, 2006. 55(5): p. 700-8. 14.
Hoogeboom, T.J., et al., The impact of waiting for total joint replacement on pain and functional status: a systematic review. Osteoarthritis Cartilage, 2009. 17(11): p. 1420-7.
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van Leeuwen, D.M., et al., Preoperative strength training for elderly patients awaiting total knee arthroplasty. Rehabil Res Pract, 2014. 2014: p. 462750.
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Saleh, K.J., et al., Quadriceps strength in relation to total knee arthroplasty outcomes. Instr Course Lect, 2010. 59: p. 119-30.
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McKay, C., H. Prapavessis, and T. Doherty, The effect of a prehabilitation exercise program on
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quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study. Pm r, 2012. 4(9): p. 647-56. 23.
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Gstoettner, M., et al., Preoperative proprioceptive training in patients with total knee arthroplasty. Knee, 2011. 18(4): p. 265-70.
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function in older adults with severe osteoarthritis. J Strength Cond Res, 2011. 25(2): p.
Huang, S.W., P.H. Chen, and Y.H. Chou, Effects of a preoperative simplified home rehabilitation
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education program on length of stay of total knee arthroplasty patients. Orthop Traumatol Surg Res, 2012. 98(3): p. 259-64.
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Figure captions:
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Figure.1: The search results and selection procedure.
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Figure.2: The risk of bias summary of the included studies.
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Figure.3: The risk of bias graph of the included studies.
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Figure.4: A forest plot diagram showing the VAS score.
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Figure.5: A forest plot diagram showing the ROM.
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Figure.6: A forest plot diagram showing the SF-36 score.
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Figure.7: A forest plot diagram showing the WOMAC score.
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Figure.8: A forest plot diagram showing the time up and go.
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Figure.9: A forest plot diagram showing the LOS.
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Credit: All figures can be printed by international journal of surgery@.
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Table 1: The characteristics of included studies Preoperative Training Group/Control group Female Patients(n)
Ages(y)
Gender (%)
Huber et al 2015 [20] Matassi et al 2014 [19] Huang et al 2012 [26] Gstoettner et
22/22
66.7/66.8
N/A
22/23
68.8/71.9
50/43.5
61/61
66/67
54.1/42.6
126/117
69.8/70.5
69.8/73.5
18/20
al 2011 [25] Swank et al
36/35
2011 [24] Topp 2009 et al [12]
26/28
Rooks et al Beaupre et al 2004 [21]
Preoperative
Type
Diagnosis
RCT
OA
30.8/29.9
RCT
OA
29/28
RCT
OA
27.1/27.2
RCT
OA
72.8/66.9
88.9/70
27.4/28.2
RCT
OA
63.1/62.6
66.7/62.9
35.9/32.9
RCT
OA
64.1/63.5
73/64
32.2/32
RCT
OA
RCT
OA
RCT
OA
14/15
67/68
65/66
67/67
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Reference
31/32
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BMI(kg/m )
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N/A
60/50
34.7/32.7 32/31
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of Weeks
Number of
Training Programme
Pneumatic
Surgical
Times/Week
(pre-training group)
Tourniquet
Approach
Surgery
extension, leg curl, and Calatayud et al 2016 [17]
8
3
hip abduction (5 sets of 10 repetitions for each exercise, with 60s rest between sets)
Huber et al 2015 [20]
4~12
N/A
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programme-total joint replacement
N/A
(NEMEX-TJR)[27]
N/A
medial
parapatellar arthrotomy
primary TKA
primary TKA
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with 10s rest between stretches):
2014 [19]
6
5
Standardized
and hamstring
surgical
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N/A
technique
training: isometric
with patellar
quadriceps, isotonic
resurfacing
primary TKA
hamstring, isotonic
quadriceps contraction
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Huang et al 2012 [26]
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5s, and dynamic stepping exercise. Muscle strength training: knee setting, 7
ankle pumping, and hip
N/A
N/A
N/A
N/A
abduction with
primary TKA
resistance Home training consisting of warming
Gstoettner et al 2011 [25]
6
N/A
up by walking, stretching and the proprioceptive training exercise learnt
1
primary TKA
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During first 3 weeks, single-joint movement while standing in chest-deep water (1~2 sets×8~12reptitions). During weeks 4~6, a total body fitness program of cardiovascular, strength, and flexibility training. Education program: crutch walking on level ground and on stairs, bed mobility and transfers, and the postoperative ROM routine. Exercise program: simple strengthening exercise with progressive resistance, warmup and cool-down
3
2
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N/A
Resistance training, flexibility, and step training
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Exercise programme(1or 2 sets×10repeats): warm-up(5-min walking), leg extension, leg curl, hip abduction, hip flexion, hip extension, foot plantar flexion, foot dorsiflexion, step ups-forward/lateral both sides, and cool down
standard anterior surgical approach
N/A
N/A
N/A
N/A
primary TKA
primary TKA
primary TKA
primary TKA
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3
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1. We made this meta-analysis to evaluate the efficacy of preoperative training programme on functional recovery in early post-operative periods after TKA. 2. Preoperative training will not improve the ROM in patients received TKA. 3. Preoperative training have the similar efficacy on functional recovery in patients following TKA compared with control group.