Prehabilitation for TKA: Preop and postop benefits

Prehabilitation, particularly in the form of exercise, has the potential to significantly improve preoperative and postoperative outcomes in patients with knee osteo­arthritis who are undergoing total knee arthroplasty. Both physiological and psychological outcomes can be positively impacted.

By Carly McKay PhD and Harry Prapavessis PhD, Lower Extremity Review October 2012

Osteoarthritis (OA) is a common condition, and its chronic symptoms of pain and joint stiffness are a leading cause of disability in those aged 65 years and older.^[1]

The prevalence of knee OA, coupled with upward-shifting population demographics, means that the number of total knee arthroplasties (TKA) performed each year is on the rise.

Upwards of three million TKAs are projected to occur annually in the US by 2030.^[2] Clinicians report satisfactory outcomes in up to 95% of arthroplasty patients,^[3] but, while the operation is effective in terms of pain reduction, improving range of motion, and correcting joint alignment, a number of factors may affect a patient’s ability to achieve full function afterward. Regaining strength and mobility is key to attaining maximal benefit from the procedure,^[4] and it has been reported that those who have surgery earlier in the progression of OA generally have a better prognosis for achieving these gains than those with more severe symptoms.^[5] Additionally, the faster patients are able to become independently mobile and perform daily living activities after surgery, the better their functional outcomes.^[6]

Given that presurgical function is the greatest predictor of postsurgical function,^[5] researchers have begun to examine the potential role of prehabilitation in patients undergoing TKA.^[7]

What is prehabilitation?

The waiting period for elective procedures can be weeks or months. During this period, many conditions, including OA, continue to progress and the patient’s health and function deteriorate.^[8] Patients therefore undergo surgery in worse condition than when they were originally diagnosed, consequently requiring greater amounts of postoperative treatment to return to a healthy state.^[8] Furthermore, as patients awaiting surgery experience the progressive worsening of their condition, the time they spend engaging in daily living activities will likely decrease due to fatigue, pain, or a loss of motivation. To prevent declines in functional capacity associated with an increasingly sedentary lifestyle, some experts have advocated the implementation of presurgical exercise programs.^[4,7]

The concept of presurgical intervention, or prehabilitation, has emerged in the literature as a potential means of ameliorating the effects of a prolonged waiting period on postoperative outcomes in a number of surgical populations, including those scheduled for colorectal and spinal surgery.

In general, the basic premise of prehabilitation is to increase the body’s functional capacity in preparation for surgery.^[4] It has been speculated that, by improving function, the patient will better withstand the physical and mental stressors of the procedure and will therefore require less intervention in the postoperative rehabilitation phase.^[7] Patients undergoing successful prehabilitation are thought to experience shorter recovery times, less dependence on caregivers after surgery, and a more rapid return to presurgical function than their counterparts receiving standard care.^[4,7,9]

As an illustration, consider two hypothetical TKA patients. Both individuals begin at the same level of function in the preoperative phase, but the prehabilitation patient is able to increase his or her functional capacity before the surgery. Although both patients experience similar magnitudes of functional decline immediately following surgery, the prehabilitation patient retains a higher level of overall function, and is therefore able to recover to a minimal level of independence much faster. The degree of difference between the prehabilitation patient and the standard care patient is likely a function of the intensity, frequency, and duration of the prehabilitation intervention.^[4]

Exercise interventions

One common concern is that exercise may exacerbate OA symptoms (primarily pain), and this concern can be enough to discourage patients from even considering exercise-based prehabilitation. There is, however, a large body of research suggesting that exercise is an effective nonpharmacological option for those with OA.

Evidence supporting the benefits of aerobic exercise has been reasonably persuasive. A meta-analysis conducted in 2004 identified 12 randomized controlled trials (11 targeting knee OA) investigating the effects of aerobic-based exercise interventions on OA symptoms.^[10] The results indicate that walking programs,^[11-14] jogging in water,^[14] and Tai Chi ^[15,16] can have significant impact on pain, joint tenderness, and functional status for OA patients.^[10] Walking programs demonstrated particular efficacy for reducing pain and disability, with reductions in self-reported pain ranging from 29% to 47% and self-reported disability during daily living activities (such as bathing, dressing, and transferring from bed to a chair) decreasing approximately 15% to 20%.^[10]

Strength training has also been consistently supported in the literature, with a recent systematic review identifying ^[18] studies that investigated the effects of lower limb strengthening on knee OA symptoms.^[17] Of these studies, 56% showed significant improvements in pain for resistance training groups versus controls.^[17] Strength training was also associated with significant improvements in physical disability in 79% of the studies in which it was measured.^[17] The effects of high-resistance (60% to 80% of one repetition maximum [RM]) training appear to be larger than the effects of low-resistance (10% to 50% of one RM) training,^[18] and isokinetic or isotonic exercises seem to be of greater benefit than simple range-of-motion or isometric exercises, as they develop functional strength in muscles used to perform daily living activities.^[19]

Because many knee OA patients elect to have TKA after they have exhausted all pharmacological treatments, exercise may be the only management option remaining during the presurgical period. Considering its efficacy in OA populations and its potential to improve surgical outcomes, exercise is therefore the primary component of many prehabilitation interventions.

Research evidence

Education, physical therapy, and exercise have all been examined as prehabilitation modalities for TKA. A recent review of 11 studies (n = 1044), five of which included TKA patients, found that preoperative education reduced patient anxiety in three studies but had no significant effect in two others.^[20] Similar discrepancies were reported for pain and length of hospital stay.^[20] In a review of five studies investigating preoperative physiotherapy, three of which focused on TKA (n = 89), Ackerman and Bennell reported no significant effect on functional outcomes or length of hospital stay for TKA patients.^[21]

Although a number of prehabilitation modalities have been investigated, exercise interventions are particularly attractive due to the physiological plausibility of their effect. Loss of lower extremity muscle strength is a strong predictor of reduced functional performance and stability during daily living activities,^[22,23] and it has been reported that muscle weakness is a better predictor of pain and disability than radiographic OA.^[24-26] Because quadriceps strength is one of the largest contributing factors to function for those with knee OA, increasing strength before surgery may allow patients to more quickly regain full function post-TKA and engage in a greater number of daily living activities in the long term. Cardiovascular fitness, healthy body weight, and optimal immune function are also crucial to recovery, as they allow patients to safely undergo anesthesia and fight off infection. Exercise can help patients to achieve these health prerequisites as well, further supporting its role in presurgical treatment.

Not surprisingly, the evidence supporting exercise as a prehabilitation intervention has been somewhat more positive than the evidence for other modalities. For TKA patients, it has been reported that exercise-based interventions produce improvements in preoperative and postoperative sit-to-stand tests,^[27,28] as well as postoperative stair ascent and descent tests ^[27,29] relative to those receiving standard care. Although there is some support for using exercise prehabilitation to improve six-minute walk distance,^[28] researchers have also found contradictory evidence related to that outcome measure.^[29]

Additionally, patients have self-reported positive effects of exercise on preoperative function.^[28,30] Some evidence suggests exercise improves postoperative self-reported function,^[28] but other studies have shown no effect ^[30] or have suggested that exercise causes steeper immediate declines postoperatively compared to a control condition.^[31] It has also been shown that exercise interventions may allow patients to walk further at discharge than those receiving standard care.^[30]

Furthermore, TKA patients participating in exercise prehabilitation have shown greater improvements in preoperative lower limb strength than controls.^[29,30] Estimates suggest that prehabilitation patients may demonstrate as much as a 54% increase in quadriceps strength following a four- to six-week intervention.^[29] Postoperatively, exercise prehabilitation has resulted in significantly greater extension strength improvements based on within-group analyses (ie, prehabilitation patients improved significantly from pre- to postoperation),^[27] but there has been no significant strength difference when comparing control groups (ie, no significant difference between prehabilitation and standard care patients after surgery).^[30]

Although the effect of exercise prehabilitation on function and strength is encouraging, its effect on pain is unclear. There is some evidence that exercise-based interventions in patients undergoing TKA result in significant pain reductions in the presurgical and postsurgical periods,^[28,29] although there may be a slight increase in preoperative pain for those engaging in aerobic-based exercise.^[31] Other studies have found no significant postoperative effect on pain.^[27,30,32]

A pilot study we recently conducted examined the effect of a prehabilitation intervention based on lower limb strength training.^[32] Twenty-two TKA patients with similar baseline strength were randomized to either an intervention training group or a placebo training group (which performed upper body exercises only), and exercised three times per week for six weeks before surgery. We found that the intervention had a large effect on quadriceps strength before TKA [F(3,18) = 0.89, p = 0.47, effect size η2 = 0.13], although there was no significant difference between groups after surgery. There was also a large effect on preoperative walking speed [F(3,18) = 1.47, p = 0.26, η2 = 0.20], but no significant effect on postoperative walking speed, stair ascent and descent speed, pain, or self-reported function.^[32]

Our results indicate that, although there may not be statistically significant improvements following strength-training prehabilitation, there may be clinically meaningful improvements in strength and mobility before surgery. This suggests that prehabilitation may be beneficial to patients during the preoperative period while they are awaiting TKA. Moreover, as this was a pilot study, it may have been underpowered to detect postoperative differences between prehabilitation patients and controls. We recommend conducting larger studies to examine the postoperative effects of this particular type of intervention.

Psychological outcomes

Although researchers have looked at the role of psychological variables in arthroplasty outcomes, they have not generally included them in prehabilitation studies in this population. Considering that prehabilitation is predicated on the notion of preparation for both the physical and mental stressors of surgery,^[7] there is a paucity of information regarding the ability of such an intervention to successfully influence preoperative psychological variables.

Of all the psychological variables that could potentially influence TKA outcomes, arthritis self-efficacy is perhaps the one most deserving of research consideration. Arthritis self-efficacy characterizes the patient’s self-confidence in managing his or her symptoms while performing daily living tasks. It has been shown that preoperative self-efficacy and expectancies can explain, on average, 10% of the outcome variance in self-reported pain, function, and health-related quality of life for TKA patients.^[33] Similar findings have been reported for objective measures of function, with van den Akker-Scheek and colleagues reporting that preoperative self-efficacy significantly predicted walking speed six months after knee or hip arthroplasty (coefficient of determination, R2 = 0.47).^[34]

Postoperative self-efficacy has been shown to influence surgical outcomes to an even greater extent than preoperative self-efficacy.^[34-37] Moon and Backer examined the effect of immediate postoperative self-efficacy on ambulation frequency and exercise performance the day following joint replacement, and found that it accounted for 8% to 33% of the variance.^[37] This is echoed in the findings of van den Akker-Scheek et al, who found that postoperative self-efficacy was a significant predictor of long-term physical and mental functioning (R2 = 0.30 and R2 = 0.53, respectively).^[34]

Figure 1. Between-group comparison of Arthritis Self-efficacy Scale39 scores [mean SD].

Self-efficacy may therefore help clarify some of the discrepancies in previous prehabilitation research, although to date it has not been well examined in this context. In our own work, after adjusting for baseline self-efficacy, participants exhibited a significant increase in arthritis self-efficacy from baseline to 12 weeks post-TKA, but the six-week strength-training prehabilitation intervention failed to elicit a significant treatment effect [F(3,18) = 0.51, p = 0.08, η2 = 0.08] (Figure 1).^[32] In this study, arthritis self-efficacy at all time points (baseline, preoperative, and six and 12 weeks post-TKA) was significantly correlated with preoperative quadriceps strength (correlation coefficient range: r = 0.43 to 0.49).^[38]

Overall, the improvements in arthritis self-efficacy in this study were tied to symptom reductions over time, although the relationship between quadriceps strength and self-efficacy may point to an important role for prehabilitation. Future studies examining this relationship will be crucial for our understanding of how strength may impact self-efficacy, and vice-versa, and how to design prehabilitation interventions to enhance this positive interaction.

Conclusion

In summary, prehabilitation has the potential to improve both preoperative and postoperative function for TKA patients. Although research has not yet determined the intervention design and dosage that will impart the greatest benefit to patients, a growing body of evidence supports exercise-based interventions for positively impacting patient outcomes. Therefore, researchers and clinicians should continue to pursue the development of prehabilitation interventions as an arthroplasty adjunct.

Carly McKay PhD is a postdoctoral fellow in the Sport Injury Prevention Research Centre at the University of Calgary in Alberta, Canada. Harry Prapavessis PhD is a professor and faculty scholar in the Exercise & Health Psychology Laboratory, School of Kinesiology, at Western University in London, Ontario, Canada.

Source Lower Extremity Review

[mdi-icon name=”book-open” size=”default” color=”black”] References

1. Osteoarthritis: epidemiology, risk factors, and pathophysiology, Garstang SV, Stitik TP. Am J Phys Med Rehabil. 2006 Nov;85(11 Suppl):S2-11; quiz S12-4.
2. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030, Kurtz S, Ong K, Lau E, Mowat F, Halpern M. J Bone Joint Surg Am.2007 Apr;89(4):780-5.
3. Osteoarthritis, Hunter DJ, Felson DT. BMJ. 2006 Mar 18;332(7542):639-42.
4. Prehabilitation in preparation for orthopaedic surgery, Ditmyer MM, Topp R, Pifer M. Orthop Nurs. 2002 Sep-Oct;21(5):43-51; quiz 52-4.
5. Outcomes of total hip and knee replacement: Preoperative functional status predicts outcomes at six months after surgery, Fortin, P. R., Clarke, A. E., Joseph, L., Liang, M. H., Tanzer, M., Ferland, D., Phillips, C., Partridge, A. J., Bélisle, P., Fossel, A. H., Mahomed, N., Sledge, C. B. and Katz, J. N. (1999) Arthritis & Rheumatism, 42: 1722–1728. doi:10.1002/1529-0131(199908)42:83.0.CO;2-R
6. Osteoarthritis, Arden E, Arden N, Hunter D. New York: Oxford University Press 2008. Library of Congress Control Number: 2007048261. ISBN: 9780199211388
7. The effect of bed rest and potential of prehabilitation on patients in the intensive care unit, Topp R, Ditmyer M, King K, Doherty K, Hornyak J 3rd. AACN Clin Issues. 2002 May;13(2):263-76.
8. The burden of wait for knee replacement surgery: effects on pain, function and health-related quality of life at the time of surgery, Desmeules F, Dionne CE, Belzile E, Bourbonnais R, Frémont P. Rheumatology (Oxford). 2010 May;49(5):945-54. doi: 10.1093/rheumatology/kep469. Epub 2010 Feb 8.
9. Rehabilitation services after total joint replacement in Ontario, Canada: can ‘prehabilitation’ programs mediate an increasing demand? Landry MD, Jaglal SB, Wodchis WP, Cooper NS, Cott CA. Int J Rehabil Res. 2007 Dec;30(4):297-303.
10. Efficacy of aerobic exercises for osteoarthritis (part II): A meta-analysis, Brosseau L, Pelland L, Wells G, Macleay L, Lamothe C, Michaud G, Lambert J, Robinson V, Tugwell P. Physical Therapy Reviews 2004; 9(3): 125-145.
11. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis, Minor MA, Hewett JE, Webel RR, Anderson SK, Kay DR. Arthritis Rheum. 1989 Nov;32(11):1396-405.
12. Effects of Long-Term Aerobic or Weight Training Regimens on Gait in an Older, Osteoarthritic Population, Stephen P. Messier, Christopher D. Thompson, Walter H. Ettinger. Journal of Applied Biomechanics Volume: 13 Issue: 2 Pages: 205-225 doi: http://dx.doi.org/10.1123/jab.13.2.205
13. Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis, Penninx BW, Messier SP, Rejeski WJ, Williamson JD, DiBari M, Cavazzini C, Applegate WB, Pahor M. Arch Intern Med. 2001 Oct 22;161(19):2309-16.
14. Compliance to exercise therapy in older participants with knee osteoarthritis: implications for treating disability, Rejeski WJ, Brawley LR, Ettinger W, Morgan T, Thompson C. Med Sci Sports Exerc. 1997 Aug;29(8):977-85.
15. Arthritis self-efficacy scales measure self-efficacy, Lorig, K. and Holman, H. (1998), Arthritis & Rheumatism, 11: 155–157. doi:10.1002/art.1790110302/em>
16. Effects of T’ai Chi training on function and quality of life indicators in older adults with osteoarthritis, Hartman CA, Manos TM, Winter C, Hartman DM, Li B, Smith JC. J Am Geriatr Soc. 2000 Dec;48(12):1553-9.
17. Strength training for treatment of osteoarthritis of the knee: a systematic review, Lange AK, Vanwanseele B, Fiatarone Singh MA. Arthritis Rheum. 2008 Oct 15;59(10):1488-94. doi: 10.1002/art.24118.
18. Investigation of clinical effects of high- and low-resistance training for patients with knee osteoarthritis: a randomized controlled trial, Jan MH, Lin JJ, Liau JJ, Lin YF, Lin DH. Phys Ther. 2008 Apr;88(4):427-36. doi: 10.2522/ptj.20060300. Epub 2008 Jan 24.
19. Clinical practice. Osteoarthritis of the knee, Felson DT. N Engl J Med. 2006 Feb 23;354(8):841-8.
20. Preoperative education for orthopaedic patients: systematic review, Johansson K, Nuutila L, Virtanen H, Katajisto J, Salanterä S. J Adv Nurs. 2005 Apr;50(2):212-23.
21. Does pre-operative physiotherapy improve outcomes from lower limb joint replacement surgery? A systematic review, Ackerman IN, Bennell KL. Aust J Physiother. 2004;50(1):25-30
22. The role of the neuromuscular system in the development, progression, and rehabilitation of osteoarthritis of the knee, Berger MJ, Doherty TJ. Crit Rev Phys Rehabil Med 2007;19(3):227-249.
23. Relative impact of radiographic osteoarthritis and pain on quadriceps strength, proprioception, static postural sway and lower limb function, Hall MC, Mockett SP, Doherty M. Ann Rheum Dis 2005;65(7):865-870.
24. Determinants of disability in osteoarthritis of the knee, T E McAlindon, C Cooper, J R Kirwan, and P A Dieppe. Ann Rheum Dis. 1993 Apr; 52(4): 258–262.
25. Quadriceps weakness in knee osteoarthritis: the effect on pain and disability, O’Reilly SC, Jones A, Muir KR, Doherty M. Ann Rheum Dis. 1998 Oct;57(10):588-94.
26. Quadriceps weakness and its relationship to tibiofemoral and patellofemoral knee osteoarthritis in Chinese: the Beijing osteoarthritis study, Baker KR, Xu L, Zhang Y, Nevitt M, Niu J, Aliabadi P, Yu W, Felson D. Arthritis Rheum. 2004 Jun;50(6):1815-21.
27. The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty, Topp R, Swank AM, Quesada PM, Nyland J, Malkani A. PM R. 2009 Aug;1(8):729-35. doi: 10.1016/j.pmrj.2009.06.003.
28. Prehabilitation before knee arthroplasty increases postsurgical function: a case study,Jaggers JR, Simpson CD, Frost KL, Quesada PM, Topp RV, Swank AM, Nyland JA. J Strength Cond Res. 2007 May;21(2):632-4.
29. Prehabilitation versus usual care before total knee arthroplasty: A case report comparing outcomes within the same individual, Brown K, Swank AM, Quesada PM, Nyland J, Malkani A, Topp R. Physiother Theory Pract. 2010 Aug;26(6):399-407. doi: 10.3109/09593980903334909.
30. Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty, Rooks DS, Huang J, Bierbaum BE, Bolus SA, Rubano J, Connolly CE, Alpert S, Iversen MD, Katz JN. Arthritis Rheum. 2006 Oct 15;55(5):700-8.
31. The effect of preoperative exercise on total knee replacement outcomes, D’Lima DD, Colwell CW Jr, Morris BA, Hardwick ME, Kozin F. Clin Orthop Relat Res. 1996 May;(326):174-82.
32. The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study, McKay C, Prapavessis H, Doherty T. PM R. 2012 Sep;4(9):647-56. doi: 10.1016/j.pmrj.2012.04.012. Epub 2012 Jun 13.
33. Impact of two types of expectancy on recovery from total knee replacement surgery (TKR) in adults with osteoarthritis, Engel C, Hamilton NA, Potter PT, Zautra AJ. Behav Med. 2004 Fall;30(3):113-23.
34. Preoperative or postoperative self-efficacy: Which is a better predictor of outcome after total hip or knee arthroplasty? Inge van den Akker-Scheek, Martin Stevens, Johan W. Groothoff, Sjoerd K. Bulstra, Wiebren Zijlstra. Patient Education and Counseling 66 (2007) 92–99. doi 10.1.1.575.595
35. Self-efficacy and goal importance in the prediction of physical disability in people following hospitalization: a prospective study, Orbell S, Johnston M, Rowley D, Davey P, Espley A. Br J Health Psychol. 2001 Feb;6(Pt 1):25-40.
36. Perceived self-efficacy, functional ability, and depressive symptoms in older elective surgery patients, Kurlowicz LH. Nurs Res. 1998 Jul-Aug;47(4):219-26.
37. Relationships among self-efficacy, outcome expectancy, and postoperative behaviors in total joint replacement patients, Moon LB, Backer J. Orthop Nurs. 2000 Mar-Apr;19(2):77-85.
38. Prehabilitation for total knee arthroplasty: A patient-centred approach to maximizing surgical outcomes, McKay CD. Electronic Thesis and Dissertation Repository 2011; Paper 205. The School of Graduate and Postdoctoral Studies, The University of Western Ontario London, Ontario, Canada
39. Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis, Lorig K, Chastain RL, Ung E, Shoor S, Holman HR. Arthritis Rheum. 1989 Jan;32(1):37-44.