controlled trials review and meta-analysis of randomised knee arthroplasty for osteoarthritis: systematic Effectiveness of physiotherapy exercise after

Objective To evaluate the effectiveness of physiotherapy exercise after elective primary total knee arthroplasty in patients with osteoarthritis. Design Systematic review. Data sources Database searches: AMED, CINAHL, Embase, King’s Fund, Medline, Cochrane library (Cochrane reviews, Cochrane central register of controlled trials, DARE), PEDro, Department of Health national research register. Hand searches:Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain) Conference Proceedings. Review methods Randomised controlled trials were reviewed if they included a physiotherapy exercise intervention compared with usual or standard physiotherapy care, or compared two types of exercise physiotherapy interventions meeting the review criteria, after discharge from hospital after elective primary total knee arthroplasty for osteoarthritis. Outcome measures Functional activities of daily living, walking, quality of life, muscle strength, and range of motion in the knee joint. Trial quality was extensively evaluated. Narrative synthesis plus meta-analyses with fixed effect models, weighted mean differences, standardised effect sizes, and tests for heterogeneity. Results Six trials were identified, five of which were suitable for inclusion inmeta-analyses. There was a small to moderate standardised effect size (0.33, 95% confidence interval 0.07 to 0.58) in favour of functional exercise for function three to fourmonthspostoperatively. There were also small to moderate weighted mean differences of 2.9 (0.61 to 5.2) for range of joint motion and 1.66 (−1 to 4.3) for quality of life in favour of functional exercise three to four months postoperatively. Benefits of treatment were no longer evident at one year. Conclusions Interventions including physiotherapy functional exercises after discharge result in short term benefit after elective primary total knee arthroplasty. Effect sizes are small to moderate, with no long term benefit. INTRODUCTION Osteoarthritis is the commonest cause of disability in older people, with painful knee osteoarthritis affecting 10% of people aged over 55 in the United Kingdom. Over 80% of patients experience limitations in performing activities of daily living, such as mobility outside the home, household chores, and work duties. In 2005, patients with osteoarthritis accounted for at least 55 495 primary knee joint arthroplasties in England and Wales. As the length of hospital stay after joint arthroplasty surgery has markedly and rapidly decreased, and given that patients who undergo knee arthroplasty may still experience considerable functional impairment postoperatively, the effectiveness of physiotherapy after discharge is a valid question. The present uncertainty regarding effectiveness makes it difficult for commissioning organisations, healthcare practitioners, and patients to make decisions regarding suchphysiotherapy.We systematically reviewed randomised controlled trials to determine the effectiveness of physiotherapy exercise after discharge in terms of improving function, quality of life, walking, range of motion in the knee joint, and muscle strength for patients with osteoarthritis after elective primary unilateral total knee arthroplasty. METHODS Searching In March 2005 and in April 2007 we identified randomised controlled trials by simultaneously searching AMED (from 1985), CINAHL (from 1982), Embase (from 1974), Kings Fund database (from 1979), and Medline (from 1966) via Knowledge Access 24/7 (KA24). We also searched the Cochrane library, PEDro physiotherapy evidence database, and the Department of Health national research register. In July 2005 and April 2007 we handsearched Physiotherapy (1985March 2007 inclusive) and Physical Therapy (1985-April 2007 inclusive) to double check for trials. The conference proceedings in the Journal of Bone and Joint Surgery (Britain) (1985-2006 inclusive) were also handsearched, as were the reference lists of included trials. As it is difficult to locate physiotherapy trials, we considered that using multiple general searches was the optimum method. This review is part of a series that included both knee and hip search terms. Table 1 Department of Primary Care and General Practice, University of Birmingham Physiotherapy Research Unit, Nuffield Orthopaedic Hospital NHS Trust, Oxford School of Community Health Sciences, University of Nottingham Correspondence to:C JMinnsLowe, Physiotherapy Research Unit, Nuffield Orthopaedic Centre NHS Trust, Oxford OX3 7LD catherine.minnslowe@noc.anglox. nhs.uk doi:10.1136/bmj.39311. 460093.BE BMJ | ONLINE FIRST | bmj.com page 1 of 9 on 20 January 2008 bmj.com Downloaded from