Effect of preoperative neuromuscular training (NEMEX-TJR) on functional outcome after total knee replacement: an assessor-blinded randomized controlled trial.
BACKGROUND
Improving functional status preoperatively through exercise may improve postoperative outcome. Previous knowledge on preoperative exercise in knee osteoarthritis is insufficient. The aim of the study was to compare the difference in change between groups in lower extremity function from baseline to 3 months after Total Knee Replacement (TKR) following a neuromuscular exercise programme (NEMEX-TJR) plus a knee school educational package (KS) or KS alone.


METHODS
45 patients (55-83 years, 53% male, waiting for TKR) were randomized to receive a minimum of 8 sessions of NEMEXTJR plus 3 sessions of KS or 3 sessions of KS alone. Function was assessed with the Chair Stand Test (CST, primary endpoint) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales focusing on daily living function (ADL) and pain (secondary endpoints). Assessments were performed immediately before and after the intervention, and at 6 weeks, 3 months and 12 months after surgery by a physiotherapist, blinded to group allocation.


RESULTS
After intervention before surgery we observed a small improvement for primary and secondary endpoints in both groups, which did not differ significantly between groups: comparing the exercise to the control group the treatment effect for the CST was -1.5 seconds (95% CI: -5.3, 2.2), for KOOS ADL and KOOS pain the treatment effect was 1.3 points (-10.1, 12.8) and -2.3 (-12.4, 7.9) respectively. At 3 months after surgery we observed a small improvement in the primary endpoint in the control group and a significant improvement in the secondary endpoints in both exercise and control groups, which did not differ significantly between groups: comparing the exercise group to the control group the treatment effect in the CST was 2.0 seconds (-1.8, 5.8), for KOOS ADL and KOOS pain the treatment effect was -4.9 points (-16.3, 6.5) and -3.3 points (-13.5, 6.8) respectively.


CONCLUSIONS
A median (IQR) of 10 (8, 14) exercise sessions before surgery showed an additional small but non-significant improvement in all functional assessments compared to patient education alone. These benefits were not sustained after TKR. Our trial doesn't give a conclusive answer to whether additional preoperative exercise on postoperative functional outcomes is beneficial.
Centre of Aging and Mobility, University Hospital Zurich and Waid City Hospital Zurich, Rämistrasse 100, Zurich, Switzerland. omega-e.huber@zhaw.ch.|School of Health Professions, Institute of Physiotherapy, Zurich University of Applied Sciences, Technikumstrasse 71, 8401, Winterthur, Switzerland. omega-e.huber@zhaw.ch.|Department of Epidemiology, Musculoskeletal Research Division CAHPRI, Maastricht University, PO Box 616, Maastricht, The Netherlands. omega-e.huber@zhaw.ch.
Erika O
EO
Huber
University of Southern Denmark, Institute of Sports Science and Clinical Biomechanics, Campusvej 55, 5230, Odense M, Denmark. eroos@health.sdu.dk.
Ewa M
EM
Roos
School of Health Professions, Institute of Physiotherapy, Zurich University of Applied Sciences, Technikumstrasse 71, 8401, Winterthur, Switzerland. andre.meichtry@zhaw.ch.
André
A
Meichtry
Department of Epidemiology, Musculoskeletal Research Division CAHPRI, Maastricht University, PO Box 616, Maastricht, The Netherlands. ra.debie@maastrichtuniversity.nl.
Rob A
RA
de Bie
Centre of Aging and Mobility, University Hospital Zurich and Waid City Hospital Zurich, Rämistrasse 100, Zurich, Switzerland. heike.bischoff@usz.ch.|Department of Geriatrics and Aging Research, University Hospital Zurich, Rämistrasse 100, Zurich, Switzerland. heike.bischoff@usz.ch.
Heike A
HA
Bischoff-Ferrari
D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D019645:Arthroplasty, Replacement, Knee; D023381:Endpoint Determination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007719:Knee Joint / Q000503:physiopathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D020370:Osteoarthritis, Knee / Q000503:physiopathology / Q000601:surgery*; D010147:Pain Measurement; D010353:Patient Education as Topic / Q000379:methods*; D011300:Preoperative Care / Q000379:methods*; D016059:Range of Motion, Articular / Q000502:physiology; D055070:Resistance Training / Q000379:methods*; D016037:Single-Blind Method; D016896:Treatment Outcome