Prehabilitation+Intervention+for+Total+Joint+Arthroplasty

If a patient participates in a total joint arthroplasty prehabilitation program versus no prehabilitation, will recovery improve, regress, remain unchanged, or will a new problem develop?
 * Purpose/****Clinical Question**

__Prehabilitation:__ preoperative rehabilitation programs (ie: prescribed and supervised exercises or physical therapy with or without cointerventions such as education, nutritional counseling, acupuncture, transcutaneous electrical nerve stimulation, etc.) 1

//Databases/Resources Used//
 * Evidence**
 * "Better Sooner and Later: Prehabilitation" from //PT in Motion// (sponsored by the APTA, 2016)
 * Citation tracking of the the article's references
 * PubMed Clinical Queries
 * CINAHL

//Search Terms//
 * "Prehabilitation"
 * "Prehabilitation" AND "Outcomes"

//Inclusion Criteria//
 * Systematic reviews with meta-analyses of randomized controlled trials exploring the effects of prehabilitation
 * Studies that evaluate the effects of prehabilitation on total joint arthroplasty

//Exclusion Criteria//
 * Studies that are limited to a specific joint or age population
 * Studies that use definitive statements with biased terms, such as "improves", "enhances", etc...

//Description of Statistics Discussed// __Confidence Interval__: a range of scores within which the true score for a variable is estimated to lie within a specified probability. 2 (p 236) __ Relative ____ Risk (RR) __ : the ratio of the risk of developing a disorder in patients with a prognostic (risk) factor compared to the risk in patients without the prognostic (risk) factor. 2 (p 236) __Weighted Mean Difference (WMD)__: the weight of a meta-analysis provides the overall estimate based on weight of studies. 3 __Effect Size__: the magnitude of the difference between two mean values; may be standardized by dividing this difference by the pooled standard deviation to compare effects measured by different scales. 2 (p 252) __Bias__: results or inferences that systematically deviate from the truth or the processes leading to such deviation. 2 (p 252)
 * Narrow CI indicates precision of estimate.
 * Used for discrete outcomes
 * Used for continuous outcomes

// Design //
 * "Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised controlled trials" - published in //The BMJ//, 2015** 1
 * 22 randomized controlled trials (1492 patients) of prehabilitation vs. no prehabilitation
 * 8 studies of total-hip placements
 * 12 studies of total-knee replacements
 * 2 studies include either hip or knee replacement

//Results// "Existing evidence from 22 randomized controlled trials suggests that prehabilitation for patients planning to undergo joint replacement does not affect postoperative pain and function to a degree that would be considered clinically relevant." 1 (p 7-8)
 * WOMAC pain score: is reduced by 6 with 95% CI (-10.6 to -1.6). Change is smaller than the minimal clinically important improvement of 9.7.
 * Function improvement (WOMAC pain subscale 1-100): improves early function by 3.9-4.0. Improvement is much smaller than minimally important difference 7.9-25.9.
 * Prehabilitation allows patients to resume ADL 0.9-1.4 days earlier than no prehabilitation. The difference is trivial.
 * Length of stay: no difference between groups. If statistical significance had been achieved, the difference would have been only 0.3 days, which is a minimal difference.
 * Some studies provide __ cointerventions __ (ie: education) in the prehabilitation. "Owing to the limited numbers of studies, meta-analysis was not performed for the effect of different types of prehabilitation (ie: exercise only vs exercise plus education)." 1 (p 13)

//Limitations of this Systematic Review//
 * Studies are small (median 81 patients) and of relatively short duration of follow-up (median 3 months).
 * Many provide inadequate description of the frequency, intensity, and duration of prehabilitation provided.

//Conclusion//
 * "Future research of sufficient power to measure clinically-relevant outcomes is required to identify which, if any, form of prehabilitation achieves better outcomes than in these trials." 1 (p 13)

//Exercise Therapy May Prolong Total Hip Arthroplasty// A long-term follow-up randomized control trial involving 109 participants with hip osteoarthritis compares a 12 week program of strengthening, flexibility, and functional exercises in addition to patient education vs patient education alone. They find the median time to joint replacement is __5.4 years__ in the exercise + education group and __3.5 years__ in the education alone group. It should be noted, however, that this exercise program is relatively short (12 weeks), and over time adherence to exercise programs decreases. 4

// Design //
 * "Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis" - Published in //Physiotherapy//, 2013** 5
 * 21 studies total: 18 randomized controlled trials, 1 unrandomized controlled trial, 2 prospective case studies
 * 13 studies of orthopedic surgeries, 8 studies of surgeries on visceral organs

//Results// The literature provides early evidence that prehabilitation may reduce length of stay and possibly provide postoperative physical benefits. 5 (p 196)
 * Quality of life: 9 studies assess this outcome. 8 show no significant difference in prehabilitation vs control. The 1 significant study looks at CABG patients.
 * Pain: 6 studies assess this outcome. 3 studies find significant improvement at 1 month and at 6 months post surgery. All 3 are orthopedic surgeries.
 * Musculoskeletal and functional task performance: 16 studies assess this outcome. 15 show significant improvement in at least 1 functional outcome (ROM, strength, functional objective test).
 * Aerobic fitness: 5 studies assess this outcome. The only study that shows significant difference looks at CABG patients.
 * Perioperative complications: 9 studies assess this outcome. 2 show significant difference; both look at visceral organ surgeries.
 * Length of stay: 11 studies assess this outcome. 4 show significant difference between prehabilitation and control, but all are visceral organ surgeries.
 * Postoperative length of stay: This is the only outcome for which a meta-analysis is used. The meta-analysis reveals a bias toward prehabilitation by showing a reduced postoperative length of stay (average of 4 days).

//Limitations of this Systematic Review//
 * Bias: Each study included in this review undergo a Cochrane risk of bias assessment, of which only 4 studies (of 21) receive a low quality of bias.
 * This study excludes patients with significant comorbidities, who represent a population that may benefit the most from prehabilitation.

//Conclusion// "At present, there is no clear evidence of benefit of total-body prehabilitation with respect to postoperative functionality or psychosocial outcomes." 5 (p 205) Future studies should examine the effect of both total-body conditioning and site-specific exercises.

// Current Prehabitation Guideline // 6 For patients who are scheduled for total-knee or total-hip replacement surgery
 * Clinical Recommendations**
 * Undergo prehabilitation once a week for 4 weeks
 * Begin prehabilitation 4-8 weeks before surgery
 * Alternative for patients with PT visit limits under health plan: single prehabilitation visit focused on education and HEP instructions

//Fast-Tracking Recovery// "Fast track is a dynamic process combining clinical and logistical enhancements to ensure the best outcome for all patients regarding faster early functional recovery and reduced morbidity. The focus is on reducing convalescence by ensuring a smooth pathway with the best available clinical treatment from admission to discharge -- and beyond." -Henrik Husted M.D. 7
 * Fast-tracking recovery includes 4 disciplines to help promote optimal results
 * Exercise
 * Education
 * Nutrition
 * Pain management

__Exercises__ What caused your patient to need a joint replacement? What issues in the patient’s strength and ROM will be fixed by the replacement? What issues will not be corrected? Base the prehabilitation exercises on the dysfunctional characteristics that will not be corrected through the arthroplasty. media type="youtube" key="LAu8G0WxmRs" width="560" height="315" align="center"
 * //Warm-Up//: 5 minutes of light walking and some stretching
 * //Strength//: Strengthening should stay within pain-free ROM. It should focus not only on the muscles that immediately surround the joint, but also the core muscles and other muscles in the chains that will be affected. Take into account the whole body. Correct the compensations that developed prior to surgery.
 * __Hip Patients__: Hip and knee bending (supine and standing), isometric hamstrings, hamstring curls, quad sets, hip abduction (supine and standing), abdominal activation (bridges), standing hip extension, gluteal sets

8 media type="youtube" key="md9mNXg4iS4" width="560" height="315" align="center"
 * __Knee Patients__: Ankle pumps, quad sets, heel slides, gluteal sets, short-arc quads, hip abduction/adduction, arm-chair pushups

9
 * //Proprioceptive Training//: Surgery and post-operative immobilization impair lower extremity proprioception. Increasing the baseline allows for a slight cushion to that baseline post-op.
 * //Cardiovascular Fitness//: Building up cardiovascular fitness allows for higher post-operative tolerance exercises due to the better baseline before surgery

__Education__ General Education: prognosis, recovery process, post-operative precautions, pain and symptom management (edema control), discharge planning, equipment recommendations, gait and transfer training, setting reasonable goals
 * Patient may have questions about the risks/benefits of surgery and the procedure; be careful to not overstep professional boundaries
 * Make sure that the patient's expectations are realistic. Patients often over-estimate their abilities, which leads to disappointment, distrust and frustration with the treatment, their health-care providers, and themselves. 10 (p 2)
 * Education needs to occur verbally to ensure that the patient is aware and understands all the information being provided. Provide pamphlets to supplement the conversation.
 * Education may reduce anxiety, perception of pain, and length of stay. 7 (p 72) Be aware of the patient's psychological state and tailor the education to his concerns, fears, and special needs. Be informative, but not overwhelming.


 * __Pain Management__
 * Physical therapists cannot prescribe medication, but they can provide coping mechanisms (ie: RICE, changing aggravating behaviors, modalities, distractions and mobilizations) to help patients handle pain before and after surgery
 * Explain that pre- and post-surgical pain will be different, so they may mentally prepare
 * Reiterate the importance of pain management/compliance because it is closely linked to quality of life, post-surgical delirium, immobilization, and falls 11 (p 2)


 * __ Nutrition __
 * Though a physical therapist cannot make a medical diagnosis or prescribe supplements/medicine, the therapist may provide the patient with general information on the importance of a balanced diet. If appropriate, provide contact information for a health care provider who can help the patient develop a plan to meet all dietary needs.
 * Reminder: "Malnutrition can lead to wound infection, delayed healing, prolonged hospitalization, increased rehabilitation time, and mortality." 10 (p 2)
 * //Weight Management//: try to maintain a healthy body composition; malnutrtition is indicated in people who are over- and under-weight
 * __Challenges for Overweight Patients__: Increases risk of pressure ulcers and skin tears due to difficulty with positioning/decreased visibility of vulnerable spots, prolongs immobilization due to lack of bariatric equipment available (may then increase CAUTI and DVT risks), fewer opportunities for mobilization if multiple staff members and additional time are needed to ensure safety, increases fall risk, risk of surgical failure (dislocation, fracture of prothesis, etc...)
 * __Challenges for Underweight Patients__: Increases risk of pressure ulcer due to protruding bony prominences, may need additional time to ambulate safely, increases fall risk if too weak/deconditioned
 * //Anemia//: low hemoglobin increases risk of infection, slows wound healing, leads to fatigue; may increase surgical bleeding/the need for transfusion and hospital length of stay 7 (p 72)
 * //Vitamin D and Calcium//: necessary for bone integrity/healing and muscle strength/stability; may reduce risk of falls and fractures 11 (p 4)
 * //Hydration//: drink plenty of water before the pre-surgical fasting period; well-hydrated patients report less post-operative nausea and can be mobilized sooner 10 (p 3) ; also have better vein access for IVs
 * //Smoking Cessation:// improves overall body function; best results if cessation occurs +4 weeks before surgery 10 (p 4)
 * Improves pulmonary and respiratory function, improves tissue healing/decreases risk of site-infection, decreases risk of surgical complications (ie: unplanned intubation), decreases risk of pneumonia and septic shock, decelerates bone breakdown, etc...

1. Wang L, Lee M, Zhang Z, Moodle J, Cheng D, Martin J. Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised controlled trials. //BMJ// 2015:1–15. doi:10.1136/bmjopen-2015-009857. 2. Jewell DV. Appraising Evidence About Interventions. In: Guide to Evidence-Based Physical Therapist Practice. 3rd ed. Burlington, MA: Jones & Bartlett Learning, LLC; 2015:251-274. 3. Sabus C. PhD. Systematic Review and Metaanalysis. Lecture Spring 2016 Research in Evidence-Based Physical Therapy Practice. 4. Svege I, Nordsletten L, Fernandes L, Risberg MA. Exercise therapy may postpone total hip replacement surgery in patients with hip osteoarthritis: a long-term follow-up of a randomised trial. Ann Rheum Dis 2015; 71: 164-9. 5. Santa Mina D, Clarke H, Ritvo P, et al. Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis. //Physiotherapy// 2013:196–207. doi:10.1016/j.physio.2013.08.008. 6. Eric R. Better Sooner and Later: Prehabilitation. //PT in Motion// 2016;8(1):20–31. 7. Rucker J. PT. PhD. Joint Arthroplasty. Lecture Spring 2016. Slide 69-74. Musculoskeletal Conditions and Treatment. 8. Hip Prehab Workout for Athletes. YouTube. 2012. Available at: https://www.youtube.com/watch?v=lau8g0wxmrs. Accessed April 12, 2016. 9. Prehab Exercises for knee surgery. YouTube. 2016. Available at: https://www.youtube.com/watch?v=md9mnxg4is4. Accessed April 12, 2016. 10. Ibrahim MS, Khan MA, IN, Haddad FS. Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review. BMC Medicine 2013:1–9. doi:10.1186/1741-7015-11-37. 11. Colón-Emeric CS. Postoperative management of hip fractures: interventions associated with improved outcomes. //BoneKEy Reports //. 2012;1:241. doi:10.1038/bonekey.2012.241.
 * References **