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Prehabilitation and Rehabilitation for Major Joint Replacement

Research Protocol

I. Background and Objectives for the Systematic Review

Osteoarthritis (OA) is a leading cause of joint disability in the United States. Approximately 54 million people (23% of adults) have OA, and, of these, 24 million are limited in their daily activities due to OA.1 Total joint replacement (TJR)—total knee arthroplasty (TKA) and total hip arthroplasty (THA)—has been one of the most successful therapies in managing pain and dysfunction of hip and knee joints for end-stage arthritis.2-5 Patients who have undergone a TKA or THA experience reduced pain and improved function and quality of life.2,6,7 As the prevalence of OA has increased, the numbers of TKAs and THAs have correspondingly increased,8 and they are now the most common inpatient surgical procedures covered by Medicare.9 In 2014, an estimated 680,150 patients in the U.S. underwent a TKA and 370,770 underwent a THA. It is expected that by 2030, 1.26 million patients will undergo a TKA annually (an 85% increase from 2014) and 635,000 will undergo a THA (71% increase).10

While most patients experience improvements in pain after TJR, deficits in functional performance and strength still commonly persist 1 year after TJR surgery for most patients.11-14 Full recovery of muscle strength and physical function to a normal level is rare.15,16 In addition, some patients have balance and movement control deficits,17 leading to higher risk of falls.18 Physical rehabilitation is commonly offered to patients undergoing TJR with the goal of optimizing postoperative outcomes, including strength, physical function, pain reduction, and return to normal activities of daily living. Increasingly, "prehabilitation" (rehabilitation services provided prior to surgery) is also considered to maximize patients’ functional status prior to surgery to improve postoperative outcomes.

The topic of prehabilitation and rehabilitation (hereafter "(p)rehabilitation") is of interest to health systems to enable evidence-based decisionmaking regarding which interventions should be offered to adults undergoing TJR for OA to achieve best clinical outcomes, reduce avoidable complications or joint failures, and be cost- and resource-effective for the health system, patients, and their caregivers. The Agency for Healthcare Research and Quality's (AHRQ) Learning Health System Panel nominated this topic as being of particular interest.

Rehabilitation programs are complex interventions that incorporate multiple specific interventions (modalities) and multiple players including various rehabilitation specialists and personnel, orthopedic surgeons and other clinicians, other caregivers, and the patient. The provided rehabilitation services can occur at different times (i.e., before or after surgery) and in different settings. Furthermore, rehabilitation is commonly personalized for individuals, depending on their specific circumstances and their response to surgery and the rehabilitation. These various factors are likely important determinants of the effectiveness of the rehabilitation programs to improve strength and mobility, reduce pain, and return the patient to their best-possible overall function. But they all have cost and resource use implications related to the features of the rehabilitation program, the personnel involved, and the location of services. Thus, there are four interrelated considerations at play in deciding on a rehabilitation program:

  1. Timing: rehabilitation can occur prior to surgery (“prehabilitation”) or after
  2. Type: rehabilitation may comprise various types or modalities (e.g., strength training, education, balance training) delivered alone or in combination
  3. Setting: rehabilitation may occur in various settings (e.g., acute inpatient, supervised nursing facility, home-based)
  4. Cost and resource use: each aspect of a rehabilitation program has its associated costs (e.g., due to specialized personnel, equipment, facility overhead)

Regarding timing, rehabilitation after TJR is the most common practice in the U.S. for those who have undergone a TKA or THA procedure. Successful rehabilitation improves pain control, walking and gait, balance, and strength, and reduces length of stay.19,20 Though less commonly used, prehabilitation (prior to surgery) has also been recommended.21 Preoperative health status is a strong predictor of favorable postoperative outcomes2,22 including reduced pain and improved functioning.23 Thus, prehabilitation is hypothesized to halt further joint deterioration in the preoperative period and accelerate improvement of function and strength postoperatively.24 However, the effectiveness of prehabilitation in TJR is unclear. A 2017 systematic review on prehabilitation for TKA or THA found conflicting evidence, with some studies finding no added benefit and others finding improvements in postoperative function, quadriceps strength, and length of stay.25 A subsequent review of prehabilitation for patients about to undergo TKA found prehabilitation was associated with decreased length of stay while limited data suggested prehabilitation made no difference on patient-reported outcomes of pain or function, stiffness, and physical role.26

Prehabilitation and rehabilitation are complex interventions, with many facets that are typically individualized for given patients’ needs, goals, capabilities, and even personalities. The type of (p)rehabilitation includes various concepts: what the intervention is, how it is implemented, and who delivers it. The overall intervention program may include various modalities (typically in combination) that are aimed at improving a range of body function and structure, and activity and participation domains. These domains have been defined by the International Classification of Functioning, Disability and Health (ICF).27 They include modalities designed to improve the mobility and  stability of joint function, movement control, power and tone of muscles, gait, endurance; along with the related goal of reducing pain. Examples of modalities include stretching exercises to improve joint mobility; use of weights to improve muscle tone, power and endurance; and stair-climbing to improve mobility, muscle power, movement control, and gait. In addition to the modalities that directly impact the ICF domains, numerous adjunctive modalities are employed to help the patient better achieve their rehabilitation goals. Examples of these include cryotherapy to reduce swelling and acute pain; mindfulness programs to reduce stress, anxiety, and pain; and neuromuscular electrical stimulation (NMES) and biofeedback devices to provide positive incentives. Each modality, and the intervention as a whole may vary in how it is delivered, for example, the duration of each session (and the use of each modality within a session), the intensity of the intervention (e.g., minimal vs. maximal extension of range of motion, fewer vs. more repetitions), and the overall duration of the program (e.g., 1 week vs. 2 months prior to surgery). Further complicating the types of (p)rehabilitation, the overall intervention (or the various modality components) may be delivered by different professionals, ancillary trained personnel, or the patients (or their caregivers) themselves.

Given the wide range of potential activities that may fall within the concept of (p)rehabilitation, it is challenging to determine even what counts as a form of (p)rehabilitation. To focus on the primary interests of the nominating health systems, we focus on structured interventions that involve health professionals or other trained individuals. Thus, for the purpose of this review, we define (p)rehabilitation to be active, structured physical activities designed to attain measurable goals of improving impairments and movement-related function as defined by the ICF.27 The intervention must be delivered, supervised, and/or monitored by a healthcare professional or other trained individual and the patient must be actively involved (i.e., not simply a passive recipient). Pharmaceutical and over-the counter interventions are outside the scope of interest.

Another important aspect of (p)rehabilitation is the setting in which it may be delivered. These vary widely, and examples include the acute hospital setting (i.e., immediately postoperative), a skilled nursing facility, outpatient rehabilitation facility, the patient’s home, or a local community center or gym. Interventions may also be delivered virtually, by internet, teleconference, Web app, or device app. Various factors contribute to the decision of the setting in which (p)rehabilitation will be delivered; for example, the patient needs, caregiver support, specific modalities employed. Cost of the (p)rehabilitation services, which is largely determined by setting, plays a major role in decisions about which services to provide. In the inpatient setting, "accelerated" rehabilitation after TKA has been associated with reduced length of stay from the acute-hospital setting.28 The impact of setting of diverse types of (p)rehabilitation programs on patient outcomes is unclear, with some research suggesting facility-based rehabilitation does not provide better recovery compared to home programs for uncomplicated TKA and THA patients,29 and other evidence suggesting early outpatient rehabilitation may lead to more rapid gains in function, strength, and reduced pain in the short term.11 Insurance status may influence patient preference for setting of care, such that patients under public insurance may be more likely to utilize home-based rehabilitation programs (supervised or unsupervised) over more resource-intensive facility-based rehabilitation programs (including inpatient rehabilitation and outpatient-based sessions).29 Although facility-based programs are more likely to have skilled, supervised personnel deliver services, evidence on the added benefit of a supervised program remains unclear.30,31

The total direct costs of care for a TJR episode include the preoperative period (for assessment and, if used, prehabilitation), operative (acute) and postoperative (postacute) periods, with as much as 40 percent of the cost occurring after discharge (70% of which are from postacute care facilities).32 Both operative and postoperative costs (for the health systems, payers, and patients) vary greatly throughout the U.S. without notable differences in outcomes. As much as a 6-fold difference has been observed in cost of care (from the perspective of the health system) for patients discharged to various types of postacute care,33 despite similarities in patient characteristics, readmission, and complication rates. TJR of the lower extremity (both THA and TKA) was the most prevalent clinical episode participating in the Centers for Medicare & Medicaid Services (CMS) bundled payment model.9 As major joint replacement surgeries and bundled payment models become more prevalent, many health systems and payers are working to understand how best to implement the most effective and also most cost-effective care for TJR patients without compromising their outcomes.34-36

Purpose of Review

This systematic review will assess the prehabilitation and rehabilitation options for patients who are undergoing (or have undergone) elective, unilateral, total knee or hip replacement surgery for OA. Specifically, the review will address:

  1. the comparative benefits and harms of preoperative active structured physical activity programs (and specific modalities) for TKA (Key Question [KQ] 1) and THA (KQ 3)
  2. the comparative benefits and harms of postoperative active structured physical activity programs (and specific modalities) for TKA (KQ 2) and THA (KQ 4).

The intended audience for this systematic review includes healthcare systems, guideline developers, orthopedic surgeons, physical therapists and other rehabilitation professionals and providers of care for patients who have undergone (or will undergo) TKA or THA for OA and are considering (p)rehabilitation. It is expected that the findings will inform individual professional practice and health system decisionmaking for (p)rehabilitation care surrounding total knee or hip replacement surgery.

II. Key Questions

  • KQ 1: What are the effects, comparative effects, and harms of (preoperative) prehabilitation services (and specific modalities) for patients with osteoarthritis undergoing elective, unilateral, total knee replacement surgery on patient-reported outcomes, performance-based outcomes, healthcare utilization, and harms?
  • KQ 2: What are the effects, comparative effects, and harms of (postoperative) rehabilitation services (and specific modalities) for patients with osteoarthritis undergoing elective, unilateral, total knee replacement surgery on patient-reported outcomes, performance-based outcomes, healthcare utilization, and harms?
  • KQ 3: What are the effects, comparative effects, and harms of (preoperative) prehabilitation services (and specific modalities) for patients with osteoarthritis undergoing elective, unilateral, total hip replacement surgery on patient-reported outcomes, performance-based outcomes, healthcare utilization, and harms?
  • KQ 4: What are the effects, comparative effects, and harms of (postoperative) rehabilitation services (and specific modalities) for patients with osteoarthritis undergoing elective, unilateral, total hip replacement surgery on patient-reported outcomes, performance-based outcomes, healthcare utilization, and harms?

For all KQs:

  • Subquestion a: Do the effects, comparative effects, harms, and vary by patient factors, such as age, sex, race/ethnicity, socioeconomic status, body mass index, and comorbidities?
  • Subquestion b: Do the effects, comparative effects, harms, and vary by surgical factors, such as surgical procedure, type of implant, perioperative protocol, type of hospital, and length of hospital stay?
  • Subquestion c: Do the effects, comparative effects, harms, and vary by setting of active structured physical activity programs?

Contextual Question

Contextual Question 1: What are the major direct and indirect cost factors for the various aspects of rehabilitation and prehabilitation around major joint replacement surgery, including such factors as personnel, setting overhead, materials, and training?

Study Eligibility Criteria

The specific eligibility criteria provided below have been refined based on discussions with a panel of Key Informants (KIs) and a Technical Expert Panel (TEP).

Two important decisions that emerged after discussions with the stakeholders were to restrict:

  1. the scope of the population to individuals who had undergone (or were planning to undergo) total, elective, unilateral, primary joint (hip or knee) replacement for osteoarthritis;  
  2. to studies published 2005 or later.

The restrictions were added to maintain the focus of the review on implementation of (p)rehabilitation pertinent to contemporary practice, to enhance applicability to the majority of patients undergoing major joint replacement. For example, the restrictions to surgery type and reason for surgery focuses the review on the large majority of patients who undergo TKA or THA; patients with other underlying conditions or receiving partial, bilateral, or revision joint replacement have different (p)rehabilitation needs and goals. The time restriction was included to account for temporal trends related to changes in surgical techniques, implants, anesthesia, and, in particular, postoperative protocols (e.g., enhanced recovery after surgery protocol and rapid hospital discharge) more commonly employed since about 2000.37 While there is no clear cutoff date to mark a practice changing shift in care, 2005 was selected as a reasonable date before which the KIs agreed that studies would be less generalizable to contemporary practice.

All Key Questions (note that criteria specific to subsets of questions are listed below):

Population(s)

  • Adults (≥18 years old) undergoing (or planning to undergo) total hip or knee replacement surgery
    • for primary osteoarthritis
    • elective (nonemergent) surgery
    • primary surgery (not revision)
    • unilateral TJR
  • Exclude: Studies where >10% of patients underwent total knee or hip replacement surgery:
    • for partial joint replacement
    • for causes other than primary osteoarthritis (e.g., cancer, trauma, rheumatoid arthritis)
    • for emergency surgery
    • for revision joint replacement
    • bilateral TJR (simultaneous in both joints)
  • N.B. Studies that report stratified or subgroup analyses of the population of interest will be included if they meet the other eligibility criteria (e.g., if they included unilateral and bilateral surgeries but report data specific to unilateral, we will include)
  • Do not exclude based on prior surgeries to other joints (including contralateral hip or knee)

Interventions

  • Active, structured physical activity or activities designed to attain measurable goals of reducing impairments and improving movement-related function as defined by the ICF
    • Any movement-related physical goal including improvements beyond the basal (or baseline) state in: mobility and stability of joint function (including flexibility and range of motion), movement control, power and tone of muscles (including strength), gait, endurance; along with the related goal of reducing pain.
    • Interventions must be sufficiently described to be replicable by a therapist or other professional
    • Single or multiple modalities (or components). For multimodal interventions, the goals of the intervention criteria refer to the overall interventions, not necessarily to each individual modality.
      We will categorize the content of the rehabilitation interventions hierarchically, first according to the intervention's components (Level I: (P)rehabilitation modalities), and second according to the underlying functional goal(s) each component seeks to address (Level II: ICF functional goals). We will continue to work with content experts and our TEP to revise the categories of this taxonomy as necessary.
      • Level I: (P)rehabilitation modalities
        • Core stability
        • Education about osteoarthritis
        • Education about/in preparation for major joint replacement
        • Education about rehabilitation following surgery
        • Ergometer cycling
        • Gait training
        • Gluteus strengthening (and other muscle groups)
        • Hamstring strengthening (and other muscle groups)
        • Joint muscle groups
        • Lower extremity muscle strength (specific muscle group not specified)
        • Quadricep strengthening (focused)
        • Range of motion exercises
        • Stability-based exercises (including balance)
        • Stair/step training (focused on capacity building)
        • Stair exercises (focused on function)
        • Transfer training
        • Walking/endurance exercise
        • Water-based exercise
        • Exclude: Continuous passive motion (CPM) will not be included as there is strong evidence, summarized in an existing systematic review,38 that that modality is ineffective. We will summarize this review.
      • Level II: ICF functional goals—Body functions
        • Mobility of joint functions
        • Stability of joint functions
        • Movement control
        • Muscle power functions
        • Muscle tone functions
        • Muscle endurance functions
        • Gait pattern functions
        • Pain
      • Level II: ICF functional goals—Activities and participation
        • Mobility
        • General tasks and demands
    • The intervention must be delivered, supervised, and/or monitored by a healthcare professional or other trained individual (e.g., physical therapist, physical therapy assistant, nurse trained in rehabilitation, health educator with training in exercise delivery or rehabilitation, other healthcare professional trained in rehabilitation)
      • Peer-led (or patient-led) interventions are eligible if monitored by a professional or other trained individual
      • The physical/healthcare professional (or other trained individual) must be involved in patient engagement and assessment of progress, and must provide ongoing feedback to the patient throughout the course of intervention
        • This interaction may be direct (e.g., in-person therapy) or remote (e.g., via app, Web, or telephone)
        • Remote therapy must include active monitoring by a physical therapist (or other trained individual), although the (p)rehabilitation therapy may be guided completely by the app
    • The patient needs to be actively involved or engaged in at least part of the intervention (and not be only a passive recipient of the intervention)
  • Interventions evaluating the combined benefit an intervention defined above with an adjunctive modality will also be included.
    Adjunctive modalities are either passively applied to patients and/or do not (on their own) have the direct goals of reducing impairments or improving movement-related function, but are used to help other modalities achieve these goals. Examples of therapies that will be considered adjunctive modalities if combined with an intervention meeting criteria above include:
    • Neuromuscular electrical stimulation (NMES)
    • Transcutaneous Electrical Nerve Stimulation (TENS)
    • Manual therapy (e.g., therapeutic massage, passive range of motion)
    • Biofeedback devices
    • Cryotherapy (or other thermal therapies)
    • Dry needling
    • Mindfulness, stress/anxiety-reduction interventions
    • Complementary and alternative therapies (excluding ingested or inhaled treatments)
    • Modalities must be sufficiently described to be replicable by a therapist or other professional
  • Exclude: Interventions that are not active, structured physical activities delivered by a healthcare professional or other trained individual, including devices not designed to be used primarily during active therapy; for example:
    • Splinting, taping
    • One-time distribution of information
    • Assistive devices (e.g., crutches vs. canes or walkers)
  • Exclude: Interventions (as a whole) without specific goals (e.g., unsupervised swimming, walking, cycling, hiking).
  • Exclude: Interventions (as a whole) without active engagement of the healthcare professional (e.g., only set-up and removal of intervention without monitoring, or healthcare professional engagement only to measure pre- and post-intervention outcome measures).
  • Exclude: Surgical or hospital process-improvement interventions (e.g., early mobilizations, enhanced recovery after surgery [ERAS], care managers, pre-anesthesia protocols)
  • Exclude: Pharmaceutical (or over-the-counter) treatments (although, allowed as part of an overall intervention)

Comparators

  • No active, structured physical activity, as defined above
    • Allow "usual care" only if the intervention arm includes well-defined modalities plus the same "usual care"
  • Other active structured physical activity (or set of activities)
  • Other adjunctive modality
  • Different duration (or intensity) of intervention
  • Different providers
  • Different setting
  • Exclude: no comparison (or comparison with only pre-intervention state)

Outcomes (*denotes important/priority outcomes that will be included in Strength of Evidence tables)

  • Patient-reported outcomes
    • Activities of daily living*
    • Patient satisfaction with care*
    • Health-related quality of life (HRQoL)*
      • We will include information on QoL extracted from quality-adjusted life years (QALY) and disability-adjusted life years (DALY) if available from cost-effectiveness analyses of relevant primary studies meeting eligibility criteria.
        • We will prioritize QALY and DALY information based on 1-year estimates (as opposed to evaluations of cumulative QALY/DALY to end-of-life).
        • We will assess comparative (or incremental) QALY/DALY for comparisons of similar groups in terms of factors such as age, underlying disability, etc. that do not bias against older or frailer adults or individuals with (non-OA-related) disabilities.
        • We will attempt to parse out what aspects of HRQoL (including QALY/DALY) are affected by (p)rehabilitation (or modalities).
    • Pain
    • Injury related to arthroplasty (e.g., fall)
    • Time lost from work
    • Measures that combine these outcome domains (e.g., Hip disability/Knee injury and osteoarthritis outcome score [HOOS/KOOS])
  • Performance-based outcomes
    • Mobility of joint function (e.g., knee range of motion)*
    • Power and tone of muscle (e.g., strength)*
    • Joint stability
    • Endurance
    • Gait
    • Balance
    • Measures that combine these domains (e.g., timed-up-and-go [TUG], stair climb test)
  • Healthcare utilization
    • Hospital- or surgical clinic-based procedures postoperatively (e.g., need for manipulation under anesthesia)*
    • Hospital readmission
    • Postoperative care (excluding physical therapy services)
  • Harms
    • Injury related to therapy intervention*
    • Other harms related to therapy intervention

Potential Modifiers

  • Patient factors:
    • Demographics (age, sex, race/ethnicity, education, region)
    • Body mass index
    • Comorbidities, including mental health and other joint comorbidities
    • Socioeconomic status, insurance status
    • Prior arthroplasty of contralateral joint
    • Preoperative symptoms/status
      • Severity of preoperative symptoms, including pain, impaired function, restricted movement, and physical activity
      • Frailty (and related assessments of preoperative function)
    • Narcotic use
    • Caregiver support (outside of (p)rehabilitation)
  • Surgical factors:
    • Surgical procedure
    • Perioperative protocols (e.g., enhanced recovery after surgery)
    • Type of implant
    • Setting of surgery
      • Type of hospital (e.g., community, referral/teaching, or urban/suburban/rural)
  • Setting factors:
    • Setting of intervention (e.g., inpatient, outpatient center, rehabilitation center, home)
    • To be considered as a modifier only regarding the same intervention provided in different settings

Timing

  • Study publication date >2005
  • ≥50% of surgeries occurred after 2005
  • Outcomes
    • Patient-reported and performance-based outcomes
      • ≥3 months postoperative for KQ 1 and 2 (TKA)
      • ≥6 months postoperative for KQ 3 and 4 (THA)
    • Healthcare utilization outcomes
      • Perioperative for KQ 1 and 3 (prehabilitation)
      • ≤3 months
      • For prehabilitation, starting at the initiation of intervention
    • Harms: duration of (p)rehabilitation intervention

Setting

  • Any setting, including:
    • Acute inpatient (postoperative)
    • Other inpatient facility (e.g., skilled nursing facility)
    • Physical therapy/rehabilitation facility (outpatient)
    • Home
    • Gym or other community center
    • Other

Design

  • RCTs, N>10 per group
  • NRCS, N>10 per group, with or without adjustment for confounders
    • Prospective or retrospective (as long as there is a clear, specific intervention)
    • Parallel or series comparisons (i.e., include "pre-post" studies that evaluate different cohorts of patients receiving vs. not receiving an intervention before and after a change in available (p)rehabilitation services)
  • Cost-effectiveness (and related) analyses (for relevant HRQoL data, as available)
  • Exclude: noncomparative (single group) studies (i.e., where all received the same intervention and there is no comparison intervention)
  • Exclude: crossover studies (where the same individual receives more than one intervention in series)
  • Exclude: case reports or series; case-control studies

Additional Criteria for KQs 1 and 3 (Prehabilitation)

Population

  • Patients in whom the decision has been made to have a joint replacement surgery
  • Exclude: Patients who are trying to avoid or delay surgery

Interventions

  • Delivered within 3 months prior to surgery
  • Exclude: Preoperative interventions designed to reduce symptoms or prevent or delay surgery; i.e., interventions not designed to be prehabilitation for planned surgery

Outcomes (in addition to those listed above for all KQs)

  • Healthcare utilization
    • Length of stay (postoperative)*
    • Posthospital disposition (e.g., to home, outpatient, skilled nursing facility, “subacute” rehabilitation, “acute” inpatient rehabilitation)*
    • Length of (postoperative) rehabilitation needed
  • Harms
    • Perioperative surgical complications

Additional Criteria for KQs 2 and 4 (Postoperative rehabilitation)

Interventions

  • Delivered within 6 months following surgery

Potential Modifiers

  • Length of hospital stay

III. Analytic Framework

Figure. Analytic Framework for KQs 1-4: Different types of prehabilitation or rehabilitation for knee or hip replacement surgery

This figure depicts the Analytic Framework for Key Questions 1 to 4 within the context of the eligibility criteria described below. In general, the figure illustrates the potential effects and harms of prehabilitation or rehabilitation in adults (≥18 year old) who are undergoing (or planning to undergo) elective, nonrevision, unilateral total knee or hip replacement surgery for primary osteoarthritis. The figure shows the comparison of active structured physical activity programs (and specific modalities) for total hip replacement or total knee replacement to no active structured physical activity or other active structured physical activity. Interventions may result in a range of beneficial outcomes following surgery including improvements in performance-based measures (e.g., mobility of joint function such as improved range of motion of the knee, power and tone of muscle such as muscle strength, joint stability, endurance, gait, balance) and patient-reported outcomes (improvements in activities of daily living, patient satisfaction with care, health-related quality of life, and reductions in pain, injury related to arthroplasty such as falls, and time lost from work). Interventions may also lead to reduced healthcare utilization (e.g., hospital- or surgical clinic-based procedures postoperatively such as manipulation under anesthesia, hospital readmission, postoperative care excluding physical therapy services). For Key Questions 1 and 3 specifically, interventions may lead to improved healthcare utilization outcomes (reduced length of stay, length of postoperative rehabilitation needed, and need for intense post-surgical care as captured by posthospital disposition). All interventions may have harms, which include injury related to therapy intervention, other harms, and for Key Questions 1 and 3, perioperative surgical complications. Potential effect modifiers may relate to demographics (age, sex, race/ethnicity), body mass index, comorbidities (including mental health and other joint comorbidities), socioeconomic status, prior arthroplasty of contralateral joint, preoperative symptoms/status, severity of preoperative symptoms, including pain, impaired function, restricted movement, and physical activity, frailty (and related assessments of preoperative function), narcotic use, caregiver support (outside of (p)rehabilitation), surgical factors (surgical procedure, perioperative protocols such as enhanced recovery after surgery, type of implant, setting of surgery (e.g. type of hospital such as community, referral/teaching or urban/suburban/rural) and for Key Questions 2 and 4 specifically, length of hospital stay, and setting factors (setting of intervention [e.g., inpatient vs. outpatient center; outpatient center vs. home] which will considered as a modifier only regarding the same intervention provided in different settings).

*denotes important/priority outcomes that will be included in Strength of Evidence tables
Abbreviations: KQ = Key Question; MUA = manipulation under anesthesia

 

IV. Methods

For all KQs, the systematic review will follow Evidence-based Practice Center (EPC) Program methodology, as laid out in its Methods Guide,39 particularly as pertain to reviews of comparative effectiveness and complex meta-analyses. As described below, the Contextual Questions will be addressed using a nonsystematic approach.

Conducting the Systematic Review (KQs 1-5)

Criteria for Inclusion/Exclusion of Studies in the Review: See Study Eligibility Criteria in Section II.

Literature Search Strategies to identify primary studies for all Key Questions: We will search for primary studies in MEDLINE (via PubMed), PsycINFO, Embase, The Cochrane Register of Clinical Trials, CINAHL, and Scopus. Duplicate citations will be removed prior to screening. We will not employ any language restrictions to the search, but will include filters to remove nonhuman studies and articles that are not primary studies and restrict studies to studies published during or after 2005 to ensure the body of evidence is consistent with contemporary surgical and rehabilitation practices. We will include MeSH or Emtree terms, along with free-text words, related to arthroplasty, knee replacement, hip replacement, total knee, total hip, rehabilitation, prehabilitation, physical therapy, physiotherapy, postoperative care. The searches will be independently peer reviewed. Appendix A includes the current search strategy for each database.

We will also run a search of the ClinicalTrials.gov registry for ongoing studies, unpublished study protocols, and unpublished study results. The reference lists of relevant existing systematic reviews will be screened for additional eligible studies. Additional articles suggested to us from any source, including peer and public review, will be screened applying identical eligibility criteria. Non-English language articles will be screened and data extracted either by readers of the relevant languages or after translation via Google Translate, if possible.

We will update the search upon submission of the draft report for public review.

Screening process: Citations from all searches will be de-duplicated and then entered into Abstrackr software to enable title and abstract screening. The team will conduct two or more rounds of pilot screening. During each pilot round, we will all screen the same 100 abstracts and discuss conflicts, with the goal of training the team in the nuances of the eligibility criteria and refining them as needed. After the pilot rounds, we will screen abstracts in duplicate. Conflicts will be discussed by the team (during the initial period of abstract screening) and then resolved by the Project Lead. The Abstrackr software has machine learning capabilities to predict the likelihood of relevance of each citation. Daily, the list of unscreened abstracts will be sorted so that most potentially-relevant articles are presented first. This process will make screening more efficient and will enable us to capture the large majority of relevant articles relatively early in the abstract screening process. Based on empirical research on Abstrackr (that is soon to be submitted for publication), when all remaining unscreened abstracts have a prediction value <0.40 (on a scale of 0 to 1), we will consider switching to single screening of remaining abstracts. The empirical research suggests that at this threshold, all remaining abstracts will be rejected. Typically, this threshold is reached when about half the abstracts have been screened. We will then stop screening if there are no eligible citations identified in a consecutive sample of 370 remaining unscreened citations (sample size chosen because the upper 97.5% confidence interval bound for a proportion of 0/370 is less than 1%).

Potentially relevant citations will be retrieved in full text. These articles will be rescreened in duplicate.

Data Extraction and Data Management: Data from eligible studies will be extracted into the Systematic Review Data Repository-Plus (SRDR+) software. Each article will be extracted by one researcher, and entered data will be confirmed by a second, independent researcher. Individual studies with multiple publications will be extracted as a single study (with a single entry in SRDR+). Each study will be entered into SRDR+ separately, even if two or more studies are reported within a single publication.

For each study, we will extract publication identifying data, study design features, population characteristics, intervention and comparator names and descriptions, relevant outcomes and their definitions, and funding source. We will extract, as available, data on the effect modifiers that are relevant to the KQs being addressed by each study.

Assessment of Methodological Risk of Bias of Individual Studies: We will evaluate each study for risk of bias and methodological quality.

Because we anticipate including a variety of study designs, we will incorporate items from three different commonly-used tools and will tailor the set of items for each study design. For all KQs, the three tools will include the Cochrane Risk of Bias Tool,40 the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool,41 and the National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment tool.42

For RCTs, we will use all the items from the Cochrane Risk of Bias tool,40 focusing on issues related to randomization and allocation concealment methodology; blinding of patients, study personnel/care providers, objective outcome assessors, and subjective outcome assessors; incomplete outcome data; selective outcome reporting; and other issues that could be related to bias.

For NRCSs, we will use the specific sections of ROBINS-I41 that pertain to confounding and selection bias. ROBINS-I requires the identification of specific confounders of interest for the systematic review. For the purpose of assessing for the presence of potential confounding in studies, we will consider demographics (such as age, sex, race/ethnicity), socioeconomic status, caregiver support, body mass index (BMI), comorbidities, prior arthroplasty of contralateral joint, narcotic use, preoperative symptoms/status (e.g., severity of symptoms including pain, impaired function, restricted movement, physical activity, frailty), surgical factors (e.g., surgical procedure or protocol, type of implant), and hospital type for all KQs. Additionally, for KQs 2 and 4 related to postoperative care, we will consider length of hospital stay as an additional potential confounder. Because NRCSs, similar to RCTs, can be impacted by the lack of blinding and by participant loss to followup, we will also use the items from the Cochrane Risk of Bias tool40 that focus on issues related to blinding of patients, study personnel/care providers, objective outcome assessors, and subjective outcome assessors; incomplete outcome data; selective outcome reporting; and other issues that could be related to bias. For both RCTs and NRCSs, we will supplement the Cochrane Risk of Bias and ROBINS-I tools with items from the NHLBI tool that pertain to the adequacy of descriptions of study eligibility criteria, interventions, and outcomes.42

For cost-effectiveness and related studies, we will evaluate their risk of bias based on the underlying source of their data (i.e., RCT, NRCS). We will not assess the quality of the cost-effectiveness analyses, per se.

Data Synthesis: We will summarize the evidence both qualitatively and, when feasible, quantitatively. Each study included in the systematic review will be described in summary and evidence tables presenting study design features, study participant characteristics, descriptions of interventions, outcome results, and risk of bias/methodological quality. Summary tables will briefly describe the studies and their findings.

For KQs 1-4, we will compare interventions with their comparators (grouped by ICF functional domains, as feasible), for their effects, primarily with odds ratios (ORs) for dichotomous outcomes (e.g., hospital readmission), net mean differences (i.e., difference-in-difference, or the between-intervention comparison of within-intervention changes) for continuous outcomes with both pre- and post-intervention data (e.g., pain or function scales), and differences (between interventions) in continuous outcome data post-intervention (e.g., patient satisfaction with care). Where there are sufficient studies reporting sufficiently similar interventions, we also plan to describe the association of intervention effects (and their components) across various levels of factors within and across studies for population, intervention, setting characteristics using hierarchical multivariable meta-regression models.43 The models (i) respect the stratification of data by trial; (ii) allow for between-study heterogeneity; (iii) can accommodate study- or arm-level covariates, and (iv) can provide predictions for versions of the intervention that have not been examined empirically. Where meta-regression or meta-analyses are not feasible (e.g., due to heterogeneity or incomplete reporting), we will synthesize findings qualitatively, describe patterns, and identify evidence gaps, as we did in past EPC reports.44 We expect to primarily rely on reported within-study differences in effects (or harms). However, we will look for opportunities to qualitatively or quantitatively compare results about harms across studies.

Grading the Strength of Evidence (SoE) for Major Outcomes and Comparisons: We will evaluate the SoE addressing each major comparison or evaluation for each KQ. We expect that these will include the following comparisons for patients undergoing prehabilitation prior to, or rehabilitation following, total knee or hip arthroplasty, respectively:

  • Relative patient-reported, performance-based, and healthcare utilization effects of active, structured physical activity (or component modalities) versus no/other active, structured physical activity before arthroplasty (or active, structured physical activity with adjunctive modality)
  • Harms of active, structured physical activity (or component modalities) and comparators (when delivered before surgery)
  • Relative patient-reported, performance-based, and healthcare utilization effects of active, structured physical activity (or component modalities) versus no/other active, structured physical activity after arthroplasty (or active, structured physical activity with adjunctive modality
  • Harms of active, structured physical activity (or component modalities) and comparators (when delivered after surgery)

We will grade the strength of the body of evidence as per the Agency for Healthcare Research and Quality (AHRQ) Methods Guide on assessing SoE.45,46 We will assess SoE for each of the important clinical outcome categories (starred outcomes in Eligibility Criteria outcome lists). We determined the relative importance of the outcomes with input from the TEP. Currently, these categories include activities of daily living; patient satisfaction with care; HRQoL; mobility of joint function (e.g., knee range of motion); power of muscle (e.g., strength); hospital- or surgical clinic-based procedures postoperatively (e.g., need for manipulation under anesthesia); and injury related to therapy intervention. Additionally for KQs 1 and 3 related to prerehabiltation, we will include length of stay (postoperative) and posthospital disposition (e.g., to home, outpatient, skilled nursing facility, "subacute" rehabilitation, "acute" inpatient rehabilitation). These outcomes domains that we are considering as important are consistent with the "core outcome sets" recommended by Osteoarthritis Research Society International (ORSI)47 and the Total Joint Arthroplasty and Outcome Measures (TJAOM)48  toolkit published in 2013 and 2014, respectively. Core outcome sets are agreed minimum sets of outcomes that should be reported in research in a given topic area.49

For each SoE assessment, we will consider the number of studies, their study designs, the study limitations (i.e., risk of bias and overall methodological quality), the directness of the evidence to the KQs, the consistency of study results, the precision of any estimates of effect, the likelihood of reporting bias, other limitations, and the overall findings across studies. Based on these assessments, we will assign a SoE rating as being either high, moderate, low, or insufficient evidence to estimate an effect.

Outcomes with highly imprecise estimates, highly inconsistent findings across studies, or with data from only one study will be deemed to have insufficient evidence to allow for a conclusion (with the exception that a particularly large and generalizable single study could provide at least low SoE). This approach is consistent with the concept that for imprecise evidence “any estimate of effect is very uncertain,” the definition of Very Low quality evidence per GRADE.50

We will summarize the data sources, basic study characteristics, and each SoE dimensional rating in a "Summary of Evidence Reviewed" table. This table will detail our reasoning for arriving at the overall SoE rating.

Assessing Applicability: For each KQ (or specific subquestion), we will assess the applicability of the included studies primarily based on the studies’ eligibility criteria and their included participants, specifically related to such factors as age, sex, and frailty or comorbidities. We will also consider operative procedures used and perioperative care in relation to their applicability to contemporary practice.

Addressing the Contextual Question

Based on data and input garnered during our systematic review of the KQs, we will answer the contextual question in a narrative format. In particular, we will assess the cost-effectiveness analyses regarding information about direct and indirect costs. We will not systematically extract or review eligible studies, create summary tables, or assess the strength of evidence for the Contextual Question.

V. References

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  30. Hansen S, Aaboe J, Mechlenburg I, et al. Effects of supervised exercise compared to non-supervised exercise early after total hip replacement on patient-reported function, pain, health-related quality of life and performance-based function - a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 2019 Jan;33(1):13-23. doi: 10.1177/0269215518791213. PMID: 30073856.
  31. Sattler LN, Hing WA, Vertullo CJ. What is the evidence to support early supervised exercise therapy after primary total knee replacement? A systematic review and meta-analysis. BMC Musculoskelet Disord. 2019 Jan 29;20(1):42. doi: 10.1186/s12891-019-2415-5. PMID: 30696416.
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VI. Abbreviations

AHRQ = Agency for Healthcare Research and Quality

AAOS = American Academy of Orthopedic Surgeons

APTA = American Physical Therapy Association

BMI = body mass index

COI = conflicts of interest

CMS = Centers for Medicare & Medicaid Services

CPG = clinical practice guideline

CPM = continuous passive motion

DALY = disability-adjusted life year

ERAS = Enhanced recovery after surgery

EPC = Evidence-based Practice Center

HOOS = Hip disability osteoarthritis outcome score

HRQoL =  Health Related Quality of Life

ICF = International Classification of Functioning, Disability and Health

KI = Key Informant

KOOS = Knee injury and osteoarthritis outcome score

KQ = Key Question

LVHN = Lehigh Valley Health Network

NHLBI = National Heart, Lung, and Blood Institute

NIAMS = National Institute of Arthritis and Musculoskeletal and Skin Diseases

NMES = neuromuscular electrical stimulation

NRCS = nonrandomized comparative study

OA = osteoarthritis

OR = odds ratio

ORSI = Osteoarthritis Research Society International

RCT = randomized controlled trial

ROBINS-I = Risk of Bias in Nonrandomized Studies of Interventions

QALY = quality-adjusted life year

QoL = quality of life

SoE = strength of evidence

TEP = Technical expert panel

TENS = Transcutaneous Electrical Nerve Stimulation

TJAOM = Total Joint Arthroplasty and Outcome Measures toolkit

TJR = total joint replacement

TKA = total knee arthroplasty

THA = total hip arthroplasty

TUG = Timed-up-and-go test

TOO = Task order officer

VII. Summary of Protocol Amendments

If we need to amend this protocol, we will give the date of each amendment, describe the change and give the rationale in this section.

VIII. Review of Key Questions

AHRQ posted the KQs on the AHRQ Effective Health Care Website for public comment. The Evidence-based Practice Center (EPC) refined and finalized them after reviewing of the public comments and seeking input from KIs. This input is intended to ensure that the KQs are specific and relevant.

IX. Key Informants (KIs)

We included a panel of KIs during Topic Refinement. KIs are end users of research, including patients and caregivers, practicing clinicians, relevant professional and consumer organizations, purchasers of health care, and others with experience in making health care decisions. Within the EPC program, the KIs’ role is to provide input into identifying and refining the Key Questions for research that will inform healthcare decisions. The EPC solicits input from KIs when developing questions for systematic review or when identifying high priority research gaps and needed new research. KIs are not involved in analyzing the evidence, writing the report, or reviewing the report, except as given the opportunity to do so through the peer or public review mechanism.

KIs must disclose any financial conflicts of interest greater than $5,000 and any other relevant business or professional conflicts of interest. Because of their role as end-users, individuals are invited to serve as KIs and those who present with potential conflicts may be retained. The Task Order Officer (TOO) and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified.

X. Technical Experts

Technical Experts constitute a multi-disciplinary group of clinical, content, and methodological experts who provide input in defining populations, interventions, comparisons, or outcomes and identify particular studies or databases to search. The Technical Expert Panel (TEP) is selected to provide broad expertise and perspectives specific to the topic under development. Divergent and conflicting opinions are common and perceived as healthy scientific discourse that fosters a thoughtful, relevant systematic review. Therefore, study questions, design, and methodological approaches do not necessarily represent the views of individual technical and content experts. Technical Experts provide information to the EPC to identify literature search strategies and suggest approaches to specific issues, as requested by the EPC. Technical Experts do not do analysis of any kind; neither do they contribute to the writing of the report. They do not review the report, except as given the opportunity to do so through the peer or public review mechanism.

Members of the TEP must disclose any financial conflicts of interest greater than $5,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals are invited to serve as Technical Experts and those who present with potential conflicts may be retained. The AHRQ TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified.

XI. Peer Reviewers

Peer reviewers are invited to provide written comments on the draft report based on their clinical, content, or methodological expertise. The EPC considers all peer review comments on the draft report in preparation of the final report. Peer reviewers do not participate in writing or editing of the final report or other products. The final report does not necessarily represent the views of individual reviewers. The EPC will complete a disposition of all peer review comments. The disposition of comments for systematic reviews and technical briefs will be published three months after the publication of the evidence report.

Potential Peer Reviewers must disclose any financial conflicts of interest greater than $5,000 and any other relevant business or professional conflicts of interest. Invited Peer Reviewers may not have any financial conflict of interest greater than $5,000. Peer reviewers who disclose potential business or professional conflicts of interest may submit comments on draft reports through the public comment mechanism.

XII. EPC Team Disclosures

EPC core team members must disclose any financial conflicts of interest greater than $1,000 and any other relevant business or professional conflicts of interest. Related financial conflicts of interest that cumulatively total greater than $1,000 will usually disqualify EPC core team investigators. 

XIII. Role of the Funder

This project was funded under Contract No. HHSA75Q80120D00001 (Task Order #02) from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The TOO will review contract deliverables for adherence to contract requirements and quality. The authors of this report will be responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

XIV. Registration

Once finalized, this protocol will be registered in the international prospective register of systematic reviews (PROSPERO).

Appendix A: Literature Search

PubMed

((arthroplast* or hip replacement* or knee replacement* or joint replacement* or total hip or total knee or total joint*)

OR "Arthroplasty, Replacement, Hip"[Mesh]

OR "Arthroplasty, Replacement, Knee"[Mesh]

OR (("Arthroplasty"[Mesh] or arthroplasty or replacement) and (knee or hip)))

AND

((pre-hab* or prehab*)

OR "Arthroplasty, Replacement, Knee/rehabilitation"[Mesh]

OR "Arthroplasty, Replacement, Hip/rehabilitation"[Mesh]

OR

((presurg* or preoperativ* or pre-surg* or pre-operativ* or early or home) and (rehab or rehabilitate or rehabilitation or re-hab* or "Rehabilitation"[Mesh] or "Physical Therapy Modalities"[Mesh] or “physical therapy” or physiotherapy*))

OR

("Preoperative Care/methods"[Mesh] OR "Preoperative Care/rehabilitation"[Mesh] )

OR

((before or prior to) and (arthroplast* or hip replacement* or knee replacement* or joint replacement* or total hip or total knee or total joint*) and (rehab or rehabilitate or rehabilitation or re-hab* or intervention* or recovery))

OR ((“Preoperative Care”[MESH] OR “Preoperative Period”[MESH]) and (rehab or rehabilitate or rehabilitation or re-hab* or "Rehabilitation"[Mesh] or "Physical Therapy Modalities"[Mesh] or “physical therapy” or physiotherapy*))

OR

(“Postoperative Period”[Mesh] and (rehab or rehabilitate or rehabilitation or re-hab*))

OR ((postsurg* or post-surg* or postoperativ* or post-operativ*) AND (rehab or rehabilitate or rehabilitation or re-hab* or "Rehabilitation"[Mesh] or "Physical Therapy Modalities"[Mesh] or “physical therapy” or physiotherapy*))

OR ((after or post) AND (arthroplast* or hip replacement* or knee replacement* or joint replacement* or total hip or total knee or total joint*) AND (rehab or rehabilitate or rehabilitation or re-hab* or "Rehabilitation"[Mesh] or "Physical Therapy Modalities"[Mesh] or “physical therapy” or physiotherapy*)))

AND

("Cohort Studies"[Mesh] OR cohort OR "Clinical Trial" [Publication Type] OR (follow-up or followup) OR longitudinal OR "Placebos"[Mesh] OR placebo* OR "Research Design"[Mesh] OR "Evaluation Study" [Publication Type] OR "Comparative Study" [Publication Type] OR ((comparative or Intervention) AND study) OR pretest* OR posttest* OR prepost* OR “before and after” OR interrupted time* OR time serie* OR intervention* OR ((quasi-experiment* OR quasiexperiment* OR quasi or experimental) and (method or study or trial or design*)) OR “real world” OR “real-world” OR "Case-Control Studies"[Mesh] OR (case and control) OR "Random Allocation"[Mesh] OR "Clinical Trial" [Publication Type] OR "Double-Blind Method"[Mesh] OR "Single-Blind Method"[Mesh] OR random* OR "Placebos"[Mesh] OR placebo OR ((clinical  OR controlled) and trial*) OR ((singl* or doubl* or trebl* or tripl*) and (blind* or mask*)) OR rct OR crossover OR cross-over OR cross-over OR RCT OR "Randomized Controlled Trial" [Publication Type] OR systematic[sb] OR meta-analysis[pt] OR meta-analysis as topic[mh] OR meta-analysis[mh] OR meta analy* OR metanaly* OR metaanaly* OR met analy* OR (systematic AND (review* OR overview*)) OR "Review Literature as Topic"[Mesh] OR cochrane[tiab] OR embase[tiab] OR (psychlit[tiab] or psyclit[tiab]) OR (psychinfo[tiab] or psycinfo[tiab]) OR (cinahl[tiab] or cinhal[tiab] OR “cumulative index to nursing and allied health”) OR science citation index[tiab] OR ibids[tiab] OR “international bibliographic information on dietary supplements” OR cancerlit[tiab] OR reference list*[tiab] OR bibliograph*[tiab] OR hand-search*[tiab] OR relevant journals[tiab] OR manual search*[tiab] OR ((selection OR inclusion OR exclusion) AND criteria[tiab]) OR data extraction[tiab] OR relevant journals OR "Systematic Review" [Publication Type])

NOT

(“address”[pt] or “autobiography”[pt] or “bibliography”[pt] or “biography”[pt] or “case reports”[pt] or “comment”[pt] or “congress”[pt] or “dictionary”[pt] or “directory”[pt] or “festschrift”[pt] or “historical article”[pt] or “interview”[pt] or “lecture”[pt] or “legal case”[pt] or “legislation”[pt] or “news”[pt] or “newspaper article”[pt] or “patient education handout”[pt] or “periodical index”[pt] or "comment on" or ("Animals"[Mesh] NOT "Humans"[Mesh]) OR rats[tw] or rat[tw] or cow[tw] or cows[tw] or chicken*[tw] or horse[tw] or horses[tw] or mice[tw] or mouse[tw] or bovine[tw] or sheep[tw] or ovine[tw] or murinae[tw] or cats[tw] or cat[tw] or dog[tw] or dogs[tw] or rodent[tw] )

CINAHL/PscyINFO

(arthroplast* or hip replacement* or knee replacement* or joint replacement* or total hip or total knee or total joint*

or ((arthroplasty or replacement) and (knee or hip)))

AND

(pre-hab* or prehab* OR

((presurg* or preoperativ* or pre-surg* or pre-operativ* or early or home) and (rehab or rehabilitate or rehabilitation or re-hab* or “physical therapy” or physiotherapy*))

OR

((before or prior to) and (arthroplast* or hip replacement* or knee replacement* or joint replacement* or total hip or total knee or total joint*) and (rehab or rehabilitate or rehabilitation or re-hab* or intervention* or recovery))

OR ((postsurg* or post-surg* or postoperativ* or post-operativ*) AND (rehab or rehabilitate or rehabilitation or re-hab* or “physical therapy” or physiotherapy*))

OR ((after or post) AND (arthroplast* or hip replacement* or knee replacement* or joint replacement* or total hip or total knee or total joint*) AND (rehab or rehabilitate or rehabilitation or re-hab* or “physical therapy” or physiotherapy*)))

Cochrane

#1  MeSH descriptor: [Arthroplasty, Replacement, Hip] explode all trees       

#2  MeSH descriptor: [Arthroplasty, Replacement, Knee] explode all trees    

#3  (arthroplast* or hip replacement* or knee replacement* or joint replacement* or total hip or total knee or total joint*)                                                                                           

#4  ((arthroplasty or replacement) and (knee or hip))                                     

#5  #1 OR #2 OR #3 OR #4                                                                        

#6  (pre-hab* or prehab* OR ((presurg* or preoperativ* or pre-surg* or pre-operativ* or early or home) and (rehab or rehabilitate or rehabilitation or re-hab* or “physical therapy” or physiotherapy*)) OR ((before or prior to) and (arthroplast* or hip replacement* or knee replacement* or joint replacement* or total hip or total knee or total joint*) and (rehab or rehabilitate or rehabilitation or re-hab* or intervention* or recovery)) OR ((postsurg* or post-surg* or postoperativ* or post-operativ*) AND (rehab or rehabilitate or rehabilitation or re-hab* or “physical therapy” or physiotherapy*)) OR ((after or post) AND (arthroplast* or hip replacement* or knee replacement* or joint replacement* or total hip or total knee or total joint*) AND (rehab or rehabilitate or rehabilitation or re-hab* or “physical therapy” or physiotherapy*)))                                                                                  

#7  #5 AND #6                                                                                           

Embase

#1  'arthropathy'/exp OR 'arthropathy'

#2  hip

#3  knee

#4  #2 OR #3

#5  #1 AND #4

#6  replacement

#7  #4 AND #6

#8  #5 OR #7

#9  'pre hab*' OR prehab* OR ((presurg* OR preoperativ* OR 'pre surg*' OR 'pre operativ*' OR early OR home) AND (rehab OR rehabilitate OR rehabilitation OR 're hab*' OR 'physical therapy' OR physiotherapy*)) OR ((before OR prior) AND to AND ((((((arthroplast* OR hip) AND replacement* OR knee) AND replacement* OR joint) AND replacement* OR total) AND hip OR total) AND knee OR total) AND joint* AND (rehab OR rehabilitate OR rehabilitation OR 're hab*' OR intervention* OR recovery)) OR ((postsurg* OR 'post surg*' OR postoperativ* OR 'post operativ*') AND (rehab OR rehabilitate OR rehabilitation OR 're hab*' OR 'physical therapy' OR physiotherapy*)) OR ((after OR post) AND ((((((arthroplast* OR hip) AND replacement* OR knee) AND replacement* OR joint) AND replacement* OR total) AND hip OR total) AND knee OR total) AND joint* AND (rehab OR rehabilitate OR rehabilitation OR 're hab*' OR 'physical therapy' OR physiotherapy*))

#10  #8 AND #9

#11  #8 AND #9 AND ([article]/lim OR [article in press]/lim) AND [2005-2020]/py