title: Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised controlled trials.
abstract: OBJECTIVE
  The clinical impact of preoperative physiotherapy on recovery after joint replacement remains controversial. This systematic review aimed to assess the clinical impact of prehabilitation before joint replacement.
  
  
  METHODS
  We searched PubMed, Embase and Cochrane CENTRAL up to November 2015 for randomised controlled trials comparing prehabilitation versus no prehabilitation before joint replacement surgery. Postoperative pain and function scores were converted to Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function subscales (0-100, high scores indicate worse outcome). Random effects meta-analysis was performed to calculate weighted mean differences (WMD, 95% CI), subgrouped by hip and knee surgery.
  
  
  METHODS
  Postoperative pain and function scores, time to resume activities of daily living, quality of life, length of hospital stay, total cost, patient satisfaction, postoperative complications, any adverse events and discontinuations.
  
  
  RESULTS
  Of 22 studies (1492 patients), 18 had high risk of bias. Prehabilitation slightly reduced pain scores within 4 weeks postoperatively (WMD -6.1 points, 95% CI -10.6 to -1.6 points, on a scale of 0-100), but differences did not remain beyond 4 weeks. Prehabilitation slightly improved WOMAC function score at 6-8 and 12 weeks (WMD -4.0, 95% CI -7.5 to -0.5), and time to climbing stairs (WMD -1.4 days, 95% CI -1.9 to -0.8 days), toilet use (-0.9 days, 95% CI -1.3 to -0.5 days) and chair use (WMD -1.2 days, 95% CI -1.7 to -0.8 days). Effects were similar for knee and hip surgery. Differences were not found for SF-36 scores, length of stay and total cost. Other outcomes of interest were inadequately reported.
  
  
  CONCLUSIONS
  Existing evidence suggests that prehabilitation may slightly improve early postoperative pain and function among patients undergoing joint replacement; however, effects remain too small and short-term to be considered clinically-important, and did not affect key outcomes of interest (ie, length of stay, quality of life, costs).
authors.affiliation: Centre for Medical Evidence, Decision Integrity and Clinical Impact (MEDICI), University of Western Ontario, London, Ontario, Canada Chinese Cochrane Centre, West China Hospital, Sichuan University, Chengdu, China Michael G DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Li
authors.initials: L
authors.lastname: Wang
authors.affiliation: Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Chungju, South Korea.
authors.forename: Myeongjong
authors.initials: M
authors.lastname: Lee
authors.affiliation: Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
authors.forename: Zhe
authors.initials: Z
authors.lastname: Zhang
authors.affiliation: Centre for Medical Evidence, Decision Integrity and Clinical Impact (MEDICI), University of Western Ontario, London, Ontario, Canada.
authors.forename: Jessica
authors.initials: J
authors.lastname: Moodie
authors.affiliation: Centre for Medical Evidence, Decision Integrity and Clinical Impact (MEDICI), University of Western Ontario, London, Ontario, Canada Department of Anesthesia & Perioperative Medicine, University of Western Ontario, London, Ontario, Canada.
authors.forename: Davy
authors.initials: D
authors.lastname: Cheng
authors.affiliation: Centre for Medical Evidence, Decision Integrity and Clinical Impact (MEDICI), University of Western Ontario, London, Ontario, Canada Department of Anesthesia & Perioperative Medicine, University of Western Ontario, London, Ontario, Canada Department of Epidemiology & Biostatistics, University of Western Ontario, London, Ontario, Canada.
authors.forename: Janet
authors.initials: J
authors.lastname: Martin
mesh_terms: D000203:Activities of Daily Living; D019644:Arthroplasty, Replacement, Hip / Q000191:economics; D019645:Arthroplasty, Replacement, Knee / Q000191:economics; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay; D015207:Osteoarthritis, Hip / Q000534:rehabilitation* / Q000601:surgery; D020370:Osteoarthritis, Knee / Q000534:rehabilitation* / Q000601:surgery; D010149:Postoperative Pain / Q000517:prevention & control; D017060:Patient Satisfaction; D026741:Physical Therapy Modalities; D011183:Postoperative Complications; D011300:Preoperative Care / Q000379:methods*; D011788:Quality of Life
keywords: JOINT REPLACEMENT; META-ANALYSIS; ORTHOPAEDIC & TRAUMA SURGERY; PAIN MANAGEMENT; REHABILITATION MEDICINE
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