Skip to main content
SpringerLink
Log in

Efficacy and safety of home-based exercises versus individualized supervised outpatient physical therapy programs after total knee arthroplasty: a systematic review and meta-analysis

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The aim of the present study was to evaluate the efficacy and safety of non-supervised home-based exercise versus individualized and supervised programs delivered in clinic-based settings for the functional recovery immediately after discharge from a primary TKA.

Methods

Medline, Embase, Cochrane, and PEDro databases were screened, from inception to April 2015, in search for randomized clinical trials (RCT) of home-based exercise interventions versus individualized and supervised outpatient physical therapy after primary TKA. Target outcomes were: knee range of motion (ROM), patient-reported pain and function, functional performance, and safety. Risk of bias was assessed with the PEDro scale. After assessing homogeneity, data were combined using random effects meta-analysis and reported as standardized mean differences or mean differences. We set a non-inferiority margin of four points in mean differences.

Results

The search and selection process identified 11 RCT of moderate quality and small sample sizes. ROM active extension data suitable for meta-analysis was available from seven studies with 707 patients, and ROM active flexion from nine studies with 983 patients. Most studies showed no difference between groups. Pooled differences were within the non-inferiority margin. Most meta-analyses showed significant statistical heterogeneity.

Conclusion

Short-term improvements in physical function and knee ROM do not clearly differ between outpatient physiotherapy and home-based exercise regimes in patients after primary TKA; however, this conclusion is based on a meta-analysis with high heterogeneity.

Level of evidence

I.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11

Similar content being viewed by others

References

  1. Akbaba YA, Yeldan I, Guney N, Ozdincler AR (2014) Intensive supervision of rehabilitation programme improves balance and functionality in the short term after bilateral total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 24(1):26–33

    Article  PubMed  Google Scholar 

  2. Altman DG, Bland JM (2011) How to obtain the confidence interval from a P value. BMJ 343:d2090

    Article  PubMed  Google Scholar 

  3. Artz N, Elvers KT, Lowe CM, Sackley C, Jepson P, Beswick AD (2015) Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis. BMC Musculoskelet Disord 16:15

    Article  PubMed  PubMed Central  Google Scholar 

  4. Baulig C, Grams M, Rohrig B, Linck-Eleftheriadis S, Krummenauer F (2015) Clinical outcome and cost effectiveness of inpatient rehabilitation after total hip and knee arthroplasty. A multi-centre cohort benchmarking study between nine rehabilitation departments in Rhineland-Palatinate (Western Germany). Eur J Phys Rehabil Med 51(6):803–813

    CAS  PubMed  Google Scholar 

  5. Büker N, Akkaya S, Akkaya N, Gokalp O, Kavlak E, Ok N, Kiter AE, Kitis A (2014) Comparison of effects of supervised physiotherapy and a standardized home program on functional status in patients with total knee arthroplasty: a prospective study. J Phys Ther Sci 26(10):1531–1536

    Article  PubMed  PubMed Central  Google Scholar 

  6. Bulthuis Y, Drossaers-Bakker KW, Taal E, Rasker J, Oostveen J, van’t Pad Bosch P, Oosterveld F, van de Laar M (2007) Arthritis patients show long-term benefits from 3 weeks intensive exercise training directly following hospital discharge. Rheumatology (Oxford) 46(11):1712–1717

    Article  CAS  Google Scholar 

  7. Busija L, Pausenberger E, Haines TP, Haymes S, Buchbinder R, Osborne RH (2011) Adult measures of general health and health-related quality of life: Medical Outcomes Study Short Form 36-Item (SF-36) and Short Form 12-Item (SF-12) Health Surveys, Nottingham Health Profile (NHP), Sickness Impact Profile (SIP), Medical Outcomes Study Short Form 6D (SF-6D), Health Utilities Index Mark 3 (HUI3), Quality of Well-Being Scale (QWB), and Assessment of Quality of Life (AQoL). Arthritis Care Res (Hoboken) 63(Suppl 11):S383–S412

    Article  Google Scholar 

  8. Chaudhary R, Beaupre LA, Johnston DW (2008) Knee range of motion during the first two years after use of posterior cruciate-stabilizing or posterior cruciate-retaining total knee prostheses. A randomized clinical trial. J Bone Joint Surg Am 90(12):2579–2586

    Article  CAS  PubMed  Google Scholar 

  9. Chughtai M, Elmallah RD, Mistry JB, Bhave A, Cherian JJ, McGinn TL, Harwin SF, Mont MA (2016) Nonpharmacologic pain management and muscle strengthening following total knee arthroplasty. J Knee Surg 29(03):194–200

    Article  PubMed  Google Scholar 

  10. Cleffken B, van Breukelen G, Brink P, van Mameren H, Olde Damink S (2007) Digital goniometric measurement of knee joint motion. Evaluation of usefulness for research settings and clinical practice. Knee 14(5):385–389

    Article  PubMed  Google Scholar 

  11. Coppola SM, Collins SM (2009) Is physical therapy more beneficial than unsupervised home exercise in treatment of post surgical knee disorders? A systematic review. Knee 16:171-175

  12. Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM (2011) Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care Res (Hoboken) 63(Suppl 11):S208–S228

    Article  Google Scholar 

  13. Dowsey MM, Choong PF (2013) The utility of outcome measures in total knee replacement surgery. Int J Rheumatol 2013:506518

    Article  PubMed  PubMed Central  Google Scholar 

  14. Elkins MR, Moseley AM, Sherrington C, Herbert RD, Maher CG (2013) Growth in the Physiotherapy Evidence Database (PEDro) and use of the PEDro scale. Br J Sports Med 47(4):188–189

    Article  PubMed  Google Scholar 

  15. Gandek B (2015) Measurement properties of the Western Ontario and McMaster Universities Osteoarthritis Index: a systematic review. Arthritis Care Res (Hoboken) 67(2):216–229

    Article  Google Scholar 

  16. Han AS, Nairn L, Harmer AR, Crosbie J, March L, Parker D, Crawford R, Fransen M (2015) Early rehabilitation after total knee replacement surgery: a multicenter, noninferiority, randomized clinical trial comparing a home exercise program with usual outpatient care. Arthritis Care Res (Hoboken) 67(2):196–202

    Article  Google Scholar 

  17. Hawker GA, Badley EM, Borkhoff CM, Croxford R, Davis AM, Dunn S, Gignac MA, Jaglal SB, Kreder HJ, Sale JE (2013) Which patients are most likely to benefit from total joint arthroplasty? Arthritis Rheum 65(5):1243–1252

    Article  PubMed  Google Scholar 

  18. Higgins JPT, Green S, Collaboration Cochrane (2008) Cochrane handbook for systematic reviews of interventions. Cochrane book series. Wiley-Blackwell, Chichester

    Book  Google Scholar 

  19. Julian LJ (2011) Measures of anxiety: State-Trait Anxiety Inventory (STAI), Beck Anxiety Inventory (BAI), and Hospital Anxiety and Depression Scale-Anxiety (HADS-A). Arthritis Care Res (Hoboken) 63(Suppl 11):S467–S472

    Article  Google Scholar 

  20. Khan F, Ng L, Gonzalez S, Hale T, Turner-Stokes L (2008) Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev 2:CD004957

    Google Scholar 

  21. Ko V, Naylor J, Harris I, Crosbie J, Yeo A, Mittal R (2013) One-to-one therapy is not superior to group or home-based therapy after total knee arthroplasty: a randomized, superiority trial. J Bone Joint Surg Am 95(21):1942–1949

    Article  PubMed  Google Scholar 

  22. Ko VWM, Naylor JM, Harris IA, Yeo AET, Crosbie J (2011) Is centre-based rehabilitation superior to home-based rehabilitation after knee replacement? A single-blind, randomised controlled trial. Arthritis Rheum 63(12):4043

    Google Scholar 

  23. Kramer JF, Speechley M, Bourne R, Rorabeck C, Vaz M (2003) Comparison of clinic- and home-based rehabilitation programs after total knee arthroplasty. Clin Orthop Relat Res 410:225–234

    Article  Google Scholar 

  24. Kurtz SM, Ong KL, Lau E, Widmer M, Maravic M, Gomez-Barrena E, de Pina Mde F, Manno V, Torre M, Walter WL, de Steiger R, Geesink RG, Peltola M, Roder C (2011) International survey of primary and revision total knee replacement. Int Orthop 35(12):1783–1789

    Article  PubMed  PubMed Central  Google Scholar 

  25. Levine M, McElroy K, Stakich V, Cicco J (2013) Comparing conventional physical therapy rehabilitation with neuromuscular electrical stimulation after TKA. Orthopedics 36(3):e319–e324

    Article  PubMed  Google Scholar 

  26. Miner AL, Lingard EA, Wright EA, Sledge CB, Katz JN, Kinemax Outcomes G (2003) Knee range of motion after total knee arthroplasty: how important is this as an outcome measure? J Arthroplasty 18(3):286–294

    Article  PubMed  Google Scholar 

  27. Mockford BJ, Thompson NW, Humphreys P, Beverland DE (2008) Does a standard outpatient physiotherapy regime improve the range of knee motion after primary total knee arthroplasty? J Arthroplasty 23(8):1110–1114

    Article  PubMed  Google Scholar 

  28. National Center for Health Statistics (2015) Health, United States, 2014: with special feature on adults aged 55–64. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Available via http://worldcat.org. http://www.cdc.gov/nchs/data/hus/hus14.pdf#105

  29. Park KK, Chang CB, Kang YG, Seong SC, Kim TK (2007) Correlation of maximum flexion with clinical outcome after total knee replacement in Asian patients. J Bone Joint Surg Br 89(5):604–608

    Article  CAS  PubMed  Google Scholar 

  30. Health Quality Ontario (2005) Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis. Ont Health Technol Assess Ser 5(8):1–91

    Google Scholar 

  31. Piqueras M, Marco E, Coll M, Escalada F, Ballester A, Cinca C, Belmonte R, Muniesa JM (2013) Effectiveness of an interactive virtual telerehabilitation system in patients after total knee arthoplasty: a randomized controlled trial. J Rehabil Med 45(4):392–396

    Article  PubMed  Google Scholar 

  32. Rajan RA, Pack Y, Jackson H, Gillies C, Asirvatham R (2004) No need for outpatient physiotherapy following total knee arthroplasty: a randomized trial of 120 patients. Acta Orthop Scand 75(1):71–73

    Article  PubMed  Google Scholar 

  33. Sindhu B, Sharma M, Biraynia RK (2013) Comparison of supervised rehabilitation vs. home based unsupervised rehabilitation programs after total knee arthroplasty: A pilot study. Indian J Physiother Occup Ther Int J 7(3):50

    Article  Google Scholar 

  34. Smarr KL, Keefer AL (2011) Measures of depression and depressive symptoms: Beck Depression Inventory-II (BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Geriatric Depression Scale (GDS), Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire-9 (PHQ-9). Arthritis Care Res (Hoboken) 63(Suppl 11):S454–S466

    Article  Google Scholar 

  35. Thomsen MG, Husted H, Otte KS, Holm G, Troelsen A (2013) Do patients care about higher flexion in total knee arthroplasty? A randomized, controlled, double-blinded trial. BMC Musculoskelet Disord 14:127

    Article  PubMed  PubMed Central  Google Scholar 

  36. Tousignant M, Moffet H, Boissy P, Corriveau H, Cabana F, Marquis F (2011) A randomized controlled trial of home telerehabilitation for post-knee arthroplasty. J Telemed Telecare 17(4):195–198

    Article  PubMed  Google Scholar 

  37. Wan X, Wang W, Liu J, Tong T (2014) Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 14:135

    Article  PubMed  PubMed Central  Google Scholar 

  38. Woolacott NF, Corbett MS, Rice SJ (2012) The use and reporting of WOMAC in the assessment of the benefit of physical therapies for the pain of osteoarthritis of the knee: findings from a systematic review of clinical trials. Rheumatology (Oxford) 51(8):1440–1446

    Article  Google Scholar 

  39. Worland RL, Arredondo J, Angles F, Lopez-Jimenez F, Jessup DE (1998) Home continuous passive motion machine versus professional physical therapy following total knee replacement. J Arthroplasty 13(7):784–787

    Article  CAS  PubMed  Google Scholar 

Download references

Authors’ contributions

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. The studies were selected by Curbelo, Perez-Porta and Nishishinya And the search strategies were designed by Rosario designed. Curbelo and Carmona wrote the article. García-Pérez and Flórez-García helped writing the article.

Source of funding

This study was self-financed and authors have no financial interest.

Author information

Authors and Affiliations

  1. Rehabilitación, Hospital Universitario Fundación Alcorcón, Madrid, Spain

    Mariano Florez-García, Fernando García-Pérez & Irene Pérez-Porta

  2. Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain

    Mariano Florez-García

  3. Instituto de Salud Musculoesquelética, Calle Conde de la Cimera, 6, 28040, Madrid, Spain

    Rafael Curbelo & Loreto Carmona

  4. Programa de doctorado en Ciencias de la Educación y el Deporte de la Facultat de Psicologia, Ciències de l’Educació i de l’Esport Blanquerna, Barcelona, Spain

    Betina Nishishinya

  5. Agencia Andaluza de Tecnologías Sanitarias, Seville, Spain

    Maria Piedad Rosario Lozano

Authors
  1. Mariano Florez-García
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Fernando García-Pérez
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rafael Curbelo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Irene Pérez-Porta
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Betina Nishishinya
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Maria Piedad Rosario Lozano
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Loreto Carmona
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Loreto Carmona.

Ethics declarations

Conflict of interest

Authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Florez-García, M., García-Pérez, F., Curbelo, R. et al. Efficacy and safety of home-based exercises versus individualized supervised outpatient physical therapy programs after total knee arthroplasty: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 25, 3340–3353 (2017). https://doi.org/10.1007/s00167-016-4231-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-016-4231-x

Keywords

Search

Navigation