title: Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis.
abstract: BACKGROUND
  Rehabilitation, with an emphasis on physiotherapy and exercise, is widely promoted after total knee replacement. However, provision of services varies in content and duration. The aim of this study is to update the review of Minns Lowe and colleagues 2007 using systematic review and meta-analysis to evaluate the effectiveness of post-discharge physiotherapy exercise in patients with primary total knee replacement.
  
  
  METHODS
  We searched MEDLINE, Embase, PsycInfo, CINAHL and Cochrane CENTRAL to October 4(th) 2013 for randomised evaluations of physiotherapy exercise in adults with recent primary knee replacement. Outcomes were: patient-reported pain and function, knee range of motion, and functional performance. Authors were contacted for missing data and outcomes. Risk of bias and heterogeneity were assessed. Data was combined using random effects meta-analysis and reported as standardised mean differences (SMD) or mean differences (MD).
  
  
  RESULTS
  Searches identified 18 randomised trials including 1,739 patients with total knee replacement. Interventions compared: physiotherapy exercise and no provision; home and outpatient provision; pool and gym-based provision; walking skills and more general physiotherapy; and general physiotherapy exercise with and without additional balance exercises or ergometer cycling. Compared with controls receiving minimal physiotherapy, patients receiving physiotherapy exercise had improved physical function at 3-4 months, SMD -0.37 (95% CI -0.62, -0.12), and pain, SMD -0.45 (95% CI -0.85, -0.06). Benefit up to 6 months was apparent when considering only higher quality studies. There were no differences for outpatient physiotherapy exercise compared with home-based provision in physical function or pain outcomes. There was a short-term benefit favouring home-based physiotherapy exercise for range of motion flexion. There were no differences in outcomes when the comparator was hydrotherapy, or when additional balancing or cycling components were included. In one study, a walking skills intervention was associated with a long-term improvement in walking performance. However, for all these evaluations studies were under-powered individually and in combination.
  
  
  CONCLUSIONS
  After recent primary total knee replacement, interventions including physiotherapy and exercise show short-term improvements in physical function. However this conclusion is based on meta-analysis of a few small studies and no long-term benefits of physiotherapy exercise interventions were identified. Future research should target improvements to long-term function, pain and performance outcomes in appropriately powered trials.
authors.affiliation: Peninsula Allied Health Centre, School of Health Professions, University of Plymouth, Plymouth, PL6 8BH, UK. Neil.Artz@plymouth.ac.uk.
authors.forename: Neil
authors.initials: N
authors.lastname: Artz
authors.affiliation: Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, BS10 5NB, UK. Karen.Elvers@bristol.ac.uk.
authors.forename: Karen T
authors.initials: KT
authors.lastname: Elvers
authors.affiliation: Physiotherapy Research Unit, Oxford United Hospitals NHS Trust, Oxford, UK. Catherine.MinnsLowe@ouh.nhs.uk.
authors.forename: Catherine Minns
authors.initials: CM
authors.lastname: Lowe
authors.affiliation: King's College London, Capital House, Guy's Campus, London, SE1 3QD, UK. Catherine.sackley@kcl.ac.uk.
authors.forename: Cath
authors.initials: C
authors.lastname: Sackley
authors.affiliation: School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. p.d.jepson@bham.ac.uk.
authors.forename: Paul
authors.initials: P
authors.lastname: Jepson
authors.affiliation: Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, BS10 5NB, UK. Andy.Beswick@bristol.ac.uk.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Beswick
mesh_terms: D000553:Ambulatory Care; D018771:Arthralgia / Q000503:physiopathology; D019645:Arthroplasty, Replacement, Knee / Q000534:rehabilitation*; D005081:Exercise Therapy / Q000379:methods; D006699:Home Care Services; D006801:Humans; D007719:Knee Joint / Q000502:physiology; D016059:Range of Motion, Articular; D020127:Recovery of Function; D016138:Walking