What is the evidence to support early supervised exercise therapy after primary total knee replacement? A systematic review and meta-analysis

Abstract Background Total knee replacement (TKR) patients participate in early supervised exercise therapy programs, despite a lack of evidence for such programs or the optimal type, duration or frequency to provide the best clinical outcomes. As hospital stay rates decrease worldwide, the first days after joint replacement surgery are of increasing clinical importance. The purpose of this study was to investigate any reported effects of published early exercise therapy following TKR surgery. Methods Databases PubMed, CINAHL, Embase, Cochrane, and Pedro were searched up to August 2018 for trials which investigated an early supervised exercise therapy, commencing within 48 h of surgery. Risk of bias was evaluated using a Modified Downs and Black Checklist and meta-analysis of results was conducted using Review Manager (RevMan). Standardised Mean Differences (SMD) or Mean Differences (MD) and 95% confidence intervals were calculated and combined in meta-analyses. Results Four studies (323 patients) that used four different interventions were identified, including Modified Quadriceps Setting, Flexion Splinting, Passive Flexion Ranging and a Drop and Dangle Flexion regime. Patients receiving the Drop and Dangle flexion protocol had superior flexion in the first 2 days after TKR and at discharge, the Flexion Splint patients were discharged earlier and had greater flexion at 6-weeks postoperatively, and the Modified Quadriceps Setting group showed greater hamstring and gluteal muscle strength. Results of the methodological quality assessment showed included studies were of moderate quality. The meta-analysis included 3 of the 4 trials and found no significant differences between groups in maximum knee flexion (MD = 1.34; 95% CI, − 5.55–8.24) or knee society scores (MD = − 1.17; 95% CI, − 4.32–1.98) assessed at 6 weeks post-operatively. Conclusion The paucity and heterogeneity of existing studies that examine early supervised exercise therapy following TKR surgery makes it challenging for clinicians to deliver high-quality evidence-based exercise programs in the early postoperative period. Although superior knee flexion range was found across differing regimes, the meta-analysis showed no significant difference in this outcome between groups at 6 weeks. The results of this review show high quality randomized clinical trials are urgently needed to evaluate the impact of early exercise following TKR surgery. Trial Registration This review was registered with PROSPERO (CRD42017081016)