Supervised neuromuscular exercise prior to hip and knee replacement

Total hip and knee replacement (THR and TKR) surgery are recognized treatments for pain relief in patients with severe symptoms from hip or knee osteoarthritis (OA). Nevertheless, one year after surgery up to 50% of patients undergoing THR and TKR may not experience clinically important improvements in pain and activities of daily living (ADL).

Aquatic exercise for knee OA. Aqua for Balance

Supervised exercise has shown to be effective treatment for reducing pain and improving ADL in patients with OA. It seems exercise at later stages of the disease, and prior to joint replacement surgery, also has beneficial results.

However, before a new treatment strategy such as pre-operative exercise is implemented, one key input into the decision-making process is the effect and cost-effectiveness of the strategy in question. Today, information on the post-operative effect of exercise prior to surgery is sparse and sufficiently powered studies with feasible interventions and longer follow-ups along with high-quality economic evaluations are warranted.

Background
There are indications of beneficial short-term effect of pre-operative exercise in reducing pain and improving activity of daily living after total hip replacement (THR) and total knee replacement (TKR) surgery. Though, information from studies conducting longer follow-ups and economic evaluations of exercise prior to THR and TKR is needed. The aim of the study was to analyse 12-month clinical effect and cost-utility of supervised neuromuscular exercise prior to THR and TKR surgery.
Methods
The study was conducted alongside a randomised controlled trial including 165 patients scheduled for standard THR or TKR at a hospital located in a rural area of Denmark. The patients were randomised to replacement surgery with or without an 8-week preoperative supervised neuromuscular exercise program (Clinical Trials registration no.: NCT01003756). Clinical effect was measured with Hip disability and Osteoarthritis Outcome Score (HOOS) and Knee injury and Osteoarthritis Outcome Score (KOOS).

Quality adjusted life years (QALYs) were based on EQ-5D-3L and Danish preference weights. Resource use was extracted from national registries and valued using standard tariffs (2012-EUR). Incremental net benefit was analysed to estimate the probability for the intervention being cost effective for a range of threshold values. A health care sector perspective was applied.

Results
HOOS/KOOS quality of life [8.25 (95% CI, 0.42 to 16.10)] and QALYs [0.04 (95% CI, 0.01 to 0.07)] were statistically significantly improved. Effect-sizes ranged between 0.09-0.59 for HOOS/KOOS subscales. Despite including an intervention cost of €326 per patient, there was no difference in total cost between groups [€132 (95% CI −3942 to 3679)]. At a threshold of €40,000, preoperative exercise was found to be cost effective at 84% probability.
Conclusion
Preoperative supervised neuromuscular exercise for 8 weeks was found to be cost-effective in patients scheduled for THR and TKR surgery at conventional thresholds for willingness to pay. One-year clinical effects were small to moderate and favoured the intervention group, but only statistically significant for quality of life measures.

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Supervised neuromuscular exercise prior to hip and knee replacement: 12-month clinical effect and cost-utility analysis alongside a randomised controlled trial, Linda Fernandes, Ewa M. Roos, Søren Overgaard, Allan Villadsen and Rikke Søgaard. BMC Musculoskeletal Disorders 201718:5 DOI: 10.1186/s12891-016-1369-0

Supervised neuromuscular exercise prior to hip or knee replacement: Cost-utility analysis alongside a randomised controlled trial, Fernandes L, Roos EM, Overgaard S, Villadsen A, Soegaard R. Osteoarthritis and Cartilage April 2015 Volume 23, A35-A36 doi: 10.1016/j.joca.2015.02.083

Effectiveness and efficiency of an 11-week exercise intervention for patients with hip or knee osteoarthritis: a protocol for a controlled study in the context of health services research, Inga Krauss, Gerhard Mueller, Georg Haupt, Benjamin Steinhilber, Pia Janssen, Nicola Jentner, and Peter Martus. BMC Public Health. 2016; 16: 367. Published online 2016 Apr 30. doi: 10.1186/s12889-016-3030-0

Postoperative effects of neuromuscular exercise prior to hip or knee arthroplasty: a randomised controlled trial, Villadsen A, Overgaard S, Holsgaard-Larsen A, Christensen R, Roos EM. Ann Rheum Dis. 2014 Jun;73(6):1130-7. doi: 10.1136/annrheumdis-2012-203135. Epub 2013 May 9.

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