Question: In patients with osteoarthritis, how effective is physiotherapy exercise in improving outcomes after elective total knee arthroplasty (TKA)?
Data sources: AMED (from 1985), CINAHL (from 1982), EMBASE/Excerpta Medica (from 1974), Kings Fund Database (from 1979), MEDLINE (from 1966), The Cochrane Library, PEDro physiotherapy evidence database, and the National Research Register of the United Kingdom Department of Health; hand searches of Physiotherapy, Physical Therapy, and the conference proceedings of The Journal of Bone and Joint Surgery (British); and reference lists of included trials.
Study selection and assessment: Randomized controlled trials (RCTs) that compared supervised physiotherapy exercise with usual care after discharge for elective TKA in patients with osteoarthritis or that compared 2 different types of relevant physiotherapy intervention. Usual care referred to the continuation at home of exercise programs that had been provided to patients during the hospital stay. Trials in which the intervention consisted of an electrical adjunct to physiotherapy were excluded. Study quality was assessed with use of quality indicators from the Consolidated Standards of Reporting Trials (CONSORT) statement and the Critical Appraisal Skills Programme (CASP) guidelines.
Main outcome measures: Functional activities of daily living, walking, range of motion, muscle strength, and quality of life.
Main results: 6 RCTs (a total of 614 patients) met the selection criteria, and 5 of the 6 RCTs were included in a meta-analysis. No compelling evidence existed for heterogeneity, and a fixed-effects model was used. 5 RCTs reported measures of function. Meta-analysis showed a small-to-moderate improvement with physiotherapy exercise at 3 months; groups did not differ at 12 months (Table). Among 3 RCTs reporting results for walking, physiotherapy exercise had no overall benefit at 3 or 12 months (Table). Among trials reporting range of motion, an increase of 2.9° occurred at 3 months with physiotherapy, with a smaller nonsignificant increase of 1° at 12 months (Table). Physiotherapy was associated with a small, nonsignificant improvement in quality of life at 3 months, with no difference at 12 months (Table). None of the trials reported on muscle strength.
Conclusions: For patients who undergo TKA for the treatment of osteoarthritis, physiotherapy exercise provides short-term benefits for functional activities of daily living and range of motion. Benefits do not persist to 1 year of follow-up.
Although recognized as one of the most cost-effective surgical interventions for patients with end-stage knee arthritis, TKA has also been identified as a high-volume, high-cost procedure. It is therefore not unexpected that the costs and benefits of procedures associated with TKA would come under greater scrutiny.
In this systematic review and meta-analysis, Minns Lowe and colleagues evaluated the effectiveness of physiotherapy after TKA in patients with osteoarthritis. This review was not an assessment of physiotherapy compared with no physiotherapy after TKA, but an assessment of supervised physiotherapy exercises compared with unsupervised home exercises. The authors commented on the paucity of rigorous studies dealing with this important subject: only 6 RCTs (a total of 614 patients) could be included in the systematic review and only 5 of the 6 RCTs could be included in the meta-analysis. The meta-analysis showed small-to-moderate improvements with supervised physiotherapy at 3 months but showed no difference between the 2 groups at 12 months.
Undoubtedly, physiotherapists who help in the rehabilitation of patients after TKA will find this review threatening and controversial. The implication of this review is that considerable cost savings could be made by substituting home exercises for supervised physiotherapy after TKA. In my opinion, such a judgment should be made with caution until additional high-quality research with greater patient enrollment is performed. In the context of a study, home-exercise patients can be regularly contacted by telephone by a physiotherapist who, if the patients are running into difficulties (e.g., loss of motion, lack of motivation, or need for support), could change the rehabilitation to a supervised program. Outside of a study, this service may not be available to patients who have been discharged home with exercises to do on their own.
Hopefully, future research will identify which TKA patients would benefit from supervised physiotherapy and which could do home exercises on their own. Furthermore, health-care providers should be encouraged to fund physiotherapists to monitor the progress of patients who have been instructed to do home exercises on their own.