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Cover of Evidence review for preoperative rehabilitation

Evidence review for preoperative rehabilitation

Joint replacement (primary): hip, knee and shoulder

Evidence review C

NICE Guideline, No. 157

.

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-3722-6

1. Preoperative rehabilitation

1.1. Review question: Is preoperative rehabilitation clinically and cost effective for people having primary elective joint replacement?

1.2. Introduction

For many people who undergo hip, knee or shoulder replacement, recovery is difficult, prolonged and often painful. Symptoms generally improve with time, but some patients never regain optimal function of their joints. People planning to undergo joint replacement could participate in preoperative rehabilitation programmes as one possible way to optimise post-operative recovery, but there are no recommended national standards for such programmes.

Most current NHS preoperative programmes, when delivered, start between two to six weeks before the planned joint replacement operation and can be one-off appointments. For individuals awaiting hip and knee replacement, they are most frequently delivered in a group setting along with others waiting for joint replacement surgery. Programmes can be delivered by a variety of healthcare professionals either alone or in combination and can include: the provision of information on the expected pathways; advice on strategies to improve recovery e.g. nutritional advice, advice on sex before and after joint replacement, reducing smoking, alcohol consumption, improving diet and other lifestyle choices; advice and provision of exercises in preparation for surgery; advice on techniques for managing activities of daily living; and the provision and practice in using adaptive equipment such as raised toilet seats, dressing aids and walking aids e.g. crutches. Similar group programmes for shoulder replacements are less common due to fewer operations being performed.

Currently there is national variation in preoperative rehabilitation provision in the UK, in terms of whether this is routinely offered, what the content of the programme is and whether this is delivered in a group setting or via a 1-to1 approach.

This review seeks to discover the clinical and cost effectiveness of preoperative rehabilitation before hip, knee or shoulder replacement and identify whether individualised programmes with specific aims delivered by a rehabilitation team are more effective than usual care.

1.3. PICO table

For full details, see the review protocol in Appendix A: dichotomous

Table 1. PICO characteristics of review question.

Table 1

PICO characteristics of review question.

1.4. Clinical evidence

1.4.1. Included studies

A search was conducted for randomised trials comparing the effectiveness of individualised preoperative rehabilitation programmes versus no program or usual care for patients awaiting primary elective hip, knee or shoulder joint replacement surgery.

Eight randomised controlled trials were included in the review;5, 6, 23, 30, 33, 38, 45, 85 these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3).

The aims of the studies included assessment of whether undertaking an individualised preoperative rehabilitation programmes improved preoperative experience, reduced length of stay in hospital, increased the speed of recovery of function after surgery and led to improved function and quality of life.

See also the study selection flow chart in Appendix C: study evidence tables in Appendix D: forest plots in Appendix E: and GRADE tables in Appendix H:

1.4.2. Excluded studies

See the excluded studies list in Appendix I:

1.4.3. Summary of clinical studies included in the evidence review

Table 2. Summary of studies included in the evidence review.

Table 2

Summary of studies included in the evidence review.

See Appendix D: for full evidence tables.

1.4.4. Quality assessment of clinical studies included in the evidence review

Table 3. Clinical evidence summary: individualised preoperative rehabilitation programmes versus usual care.

Table 3

Clinical evidence summary: individualised preoperative rehabilitation programmes versus usual care.

See Appendix F: for full GRADE tables.

1.5. Economic evidence

1.5.1. Included studies

One health economic study was identified with the relevant comparison and it has been included in this review.5 It is summarised in the health economic evidence profile below (Table 5) and the health economic evidence table in Appendix H:

1.5.2. Excluded studies

One health economic study that was relevant to this question was excluded due to an assessment of very serious limitations – see Appendix I:

See also the health economic study selection flow chart in Appendix G:

1.5.3. Unit costs

The weighted average of the HRG codes for primary elective hip, knee and shoulder replacements in Table 4 are based upon the average length of stay and average cost of an excess bed day.

Table 4. Weighted average unit cost for hip, knee and shoulder HRG codes.

Table 4

Weighted average unit cost for hip, knee and shoulder HRG codes.

1.5.4. Summary of studies included in the economic evidence review

Table 5. Health economic evidence profile: Preoperative rehabilitation versus no preoperative rehabilitation.

Table 5

Health economic evidence profile: Preoperative rehabilitation versus no preoperative rehabilitation.

1.6. Evidence statements

1.6.1. Clinical evidence statements

Evidence from 8 studies reported on people who are scheduled for hip or knee replacement surgery. No evidence was found for people scheduled for shoulder replacement surgery. The evidence review found no clinically important difference between individualised preoperative rehabilitation programs and usual care through 2 quality of life outcomes, 5 PROMs outcomes and 2 pain outcomes (moderate to very low quality, range of n=36–109). Evidence indicated a clinically important benefit for individualised preoperative rehabilitation programmes in terms of length of stay (4 studies, very low quality, n=531) and function (1 study, very low quality, n=33). No evidence was available for revision of joint replacement, depression or disability.

1.6.2. Health economic evidence statements

One cost-consequence analysis found that preoperative rehabilitation was only marginally more costly compared to usual care for patients waiting for total knee replacement with an indeterminate effect on quality of life. This analysis was assessed as partially applicable with potentially serious limitations.

1.7. The committee’s discussion of the evidence

1.7.1. Interpreting the evidence

1.7.1.1. The outcomes that matter most

The critical outcomes were agreed to be quality of life (QOL), Patient Reported Outcome Measures (PROMs), time until joint replacements were revised, depression, and disability. PROMs measure health gain in patients undergoing joint replacement. PROMs vary in terms of content and can cover a range of clinical measures such as QOL, pain, stiffness, and function. Disability gives an indication of a person’s function, and consequently their ability to return to work or undertake leisure activities. Returning to work and leisure activities can be important in terms of a person’s QOL.

Important outcomes were hospital readmissions, muscle atrophy, and length of stay. It was agreed to utilise function or pain outcomes if they were reported separately and not included in a PROM extracted from the same study.

The follow-up timescales for QOL, PROMs, disability and function were 6 to 24 months. The committee agreed the meaningful longer-term effects of preoperative rehabilitation could be expected 6 months after surgery until 2 years after surgery. Adverse outcomes such as depression, muscle atrophy and pain could be measured up to 2 years after surgery. The hospital readmissions timescale was elected to be within 90 days to pick up varying serious clinical outcomes that can occur, for example surgical site infections, dislocations, thromboembolic disorders, postoperative pain and cardiac dysrhythmia.

30-day mortality after joint arthroplasty is a rare event usually due to pre-existing cardiovascular and/or pulmonary disease and the committee did not consider this to be altered by the usage of prescribed and supervised exercises and advice by a member of the rehabilitation team.

No evidence was found for the following critical outcomes: revision of joint replacement, depression, or disability.

1.7.1.2. The quality of the evidence

There were 11 outcomes analysed from the studies, evidence quality tended to be graded as low or very low though in 1 case it was determined to be moderate. All outcomes were downgraded in quality due to risk of bias and in many cases due to imprecision. The most common reasons for increased risk of bias were lack of blinding of participants or outcome assessors and unclear methods of allocation concealment. The data from 1 study was considered indirect because it was unclear how many participants undertook the physical conditioning programme and thus the exercise aspect of the programme might have had limited coverage

1.7.1.3. Benefits and harms

The purpose of this clinical question was to consider a ’bigger package’ than usual care. Usual care in hip or knee replacement consists of 1 to 2 group sessions with exercises and information about the surgery in terms of what to expect from the surgery, what is expected of them at the hospital and the postoperative process after the surgery. These are standardised rather than individualised programmes and should be provided to all people undergoing hip or knee joint replacement surgery at the very least. The committee conceptualised a bigger package of preoperative rehabilitation for hip and knee joint replacement surgery as an individualised programme with information on the surgery and the process in hospital with expectations of the outcome including possible adverse events, exercise interventions, assessment of ADL performance with advice and interventions to maximise ongoing independence, and health psychological assessment. This could include counselling, cognitive therapy, weight control, pain medication review, and optimised medication usage, all being given several weeks before the date of surgery. It was stated that information around sex after surgery can be of great importance to people and can play a key role in maintaining wellbeing. A committee member indicated that some of these aspects could plainly benefit people undergoing shoulder replacement surgery who currently receive no pre-operative input. The committee believe these interventions would be important for general health, cardiovascular health and maintenance of function and would be effective preparation for the joint replacement surgery. The educational and health psychology to enable a patient to be ready for discharge combined with exercise therapy and ADL advice / intervention to increase the speed of functional recovery. Preoperative rehabilitation could make people better able to deal with the possible complications after joint replacement surgery, promote understanding and engagement with postoperative rehabilitation, and prepare the person better for existing with a replaced joint. The outpatient aspects of these benefits would not be based on a reduction in length of stay and therefore could therefore apply to shoulder replacement surgery as well as hip and knee replacement surgery.

Eight randomised controlled trials were included in this evidence review. The people in the studies either had hip or knee replacement surgery. There were no studies including people who had shoulder replacement surgery. The preoperative rehabilitation interventions themselves contained aspects of the committee’s understanding of what it should be but none had the combined duration, intensity and breadth of that specified as ideal by the committee. The committee concluded that this limited the abilities of the studies to show the true benefits of preoperative rehabilitation though benefits were seen in terms of function and length of stay.

The results of the evidence review saw no clinically important difference in terms of quality of life or in terms of 5 PROMs outcomes, and pain. In all cases, only 1 study reported on each outcome. A clinically important benefit for individualised preoperative rehabilitation programmes was seen in terms of length of stay, which was reported in 4 studies and function, which was reported in a single study.

The committee agreed that the RCTs included in the evidence review were small and underpowered to show a clinically important benefit in terms of preoperative rehabilitation. In addition, the evidence informing the outcomes tended to be graded low or very low quality and this reduced trust in the evidence being an accurate representation of the interventions.

The length of stay data was consistent in all studies showing a reduction in the preoperative rehabilitation intervention group. However, 3 studies showed a small and consistent reduction whereas 1 study showed a much greater reduction. It was unclear why there was such variation in effect size, though the committee noted that this could have been influenced by the background healthcare setting. The meta-analysis of length of stay indicated a reduction of 1.22 days per person. However the committee noted that the mean length of stay in studies included in the review control arms were much higher than the current length of stay in NHS care. The review shows a mean of 8.9 days in the control arms, whereas the current NHS length of stay is 4.5 days for total knee arthroplasty, based on the current evidence available and the committee’s clinical expertise. The committee considered the NHS length of stay is lower than the studies due to the effectiveness of usual care and the improvements that have happened in surgery and perioperative care. Therefore the committee agreed that a1.22 day reduction in length of stay in the NHS setting was unlikely to be fully realised but even reduced estimations could still be clinically and cost effective for NHS care. A lay member on the committee stated that wellbeing is improved by earlier discharge home and that these reductions would be of value to people who have had joint replacement surgery. The committee agreed that a mean reduction of 1 third of a day would still be a clinically important benefit. In terms of shoulder replacement, a committee member commented that shoulder replacement length of stay tends to be 1 night and shoulder replacement surgery in the USA is regularly undertaken as a day case. This very short length of stay and possible movement to a day case model means people having shoulder replacement surgery have a different length of stay model compared to people having hip and knee joint replacement. The committee agreed that length of stay is less of a driver for this intervention for shoulder joint replacement surgery.

The committee commented on the lack of consistency of the preoperative rehabilitation interventions in the RCTs included in the review. All included at least some form of exercise and advice and the sessions were individualised and as stated in the protocol with more than 1 rehabilitation session. There was inter-study variation in the exercise and information offered in terms of content and number of sessions and studies often included additional sessions, for example relaxation techniques or cognitive therapy within the preoperative rehabilitation. Thus it was difficult to exactly define what preoperative rehabilitation was in terms of the included randomised controlled trials outside of the definitive prescribed and supervised exercises and advice by a member of the rehabilitation team. Taken as a whole, the preoperative rehabilitation programmes found in the evidence-covered all the aspects stated by the committee. However no single study contained a preoperative rehabilitation programme that covered them all.

The interventions started at varying times before surgery, in 1 case it ranged from 1 to 24 weeks prior to surgery though multiple studies started 1 month prior to surgery. The committee agreed that exercise therapy is best undertaken at least 6 week prior to surgery and that this tended not to happen in the included studies and it was noted that this may have led to reduced positive effects of the intervention.

The committee also agreed through the evidence and consensus to offer preoperative rehabilitation advice to people having primary hip or knee replacement surgery but could not make a recommendation for people having shoulder replacement surgery. The committee stated a minimum set of areas that should be covered such as exercise advice, lifestyle advice, and advice about maximising functional independence and quality of life before and after surgery. This would include mobility independence. In addition the committee stated that wellbeing is a broad concept that includes personal dignity (including treatment of the individual with respect) physical and mental health and emotional wellbeing. They concluded preoperative rehabilitation could make people better able to deal with the possible complications after surgery, promote understanding and engagement with postoperative rehabilitation, and prepare the person better for existing with a replaced joint. The committee did not feel the evidence was strong enough to recommend an individualised programme and the advice offered was more similar to those in detailed in the RCTs included rather than the fuller programme detailed in the research recommendation. The committee discussed the type of exercises to prescribe. They agreed that these should be tailored to the person’s needs and circumstances, taking into account their activities of daily living. No timing aspect was stated in the recommendation as the committee were conscious that while lengthier rehabilitation could be more effective, it could delay surgery and that might be in conflict with the wishes of people undergoing the surgery due to the continued pain, impaired function, and reduced quality of life.

The committee spoke about their understanding of similarities and differences inherent between shoulder replacement surgery and hip or knee replacement surgery. The similarities can be seen in terms of the benefits of giving structured individualised information on the surgery itself, and the possible postoperative experiences in the immediate and long term. Also there are benefits to having good cardiovascular exercise prior to surgery in the post-surgery period. However the committee did not feel there was a great deal of benefit attempting to learn post-surgery exercise routines prior to surgery as the exercises are unlikely to be possible before surgery. For similar reasons it is not possible to build up important muscle groups in the affected arm prior to surgery. Finally the number of people having shoulder replacement surgery is much lower than those having hip or knee surgery and the committee were unsure provision of preoperative rehabilitation would be cost saving or cost neutral in this group. Based on the lack of evidence of clinical benefit and uncertainty around the cost of preoperative rehabilitation the committee decided not to make a recommendation in people having shoulder replacement surgery.

The committee commented that there is a lack of research in this field and made a research recommendation to investigate a fuller, earlier programme of preoperative rehabilitation before hip, knee or shoulder replacement surgery with the usual care as comparator. This research should indicate whether or not there are additional benefits in the preoperative period to be found on top of current care when a full preoperative rehabilitation programme is employed.

1.7.2. Cost effectiveness and resource use

A single published economic evaluation was included. It found that preoperative rehabilitation was only marginally more costly compared with no preoperative rehabilitation for people waiting for primary total knee replacement. No evidence was found for hip and shoulder population.

This study was a randomised controlled trial included in the above clinical review. The length of stay reduction was typical of studies in that review, although the baseline mean length of stay was substantially higher than is typical in the UK today. The intervention was particularly intensive and the cost savings were partly attributable to reduction in readmissions, which was not studied in the other trials. The study also had limited applicability, since it was conducted in a Canadian setting, nearly twenty years ago and it was underpowered to detect an improvement in quality of life.

The committee expressed concerns about recommending a full preoperative rehabilitation programme (including a personalised, comprehensive and intensive intervention) due to the large resource impact and limitations of the evidence. However, the committee felt that the clinical and economic evidence was sufficient to make a strong recommendation in favour of advice on preoperative rehabilitation for people waiting for hip, and knee replacement. As the recommendation only concerns advice on preoperative rehabilitation, rather than a full programme, the recommendation will not have a large resource impact.

The recommendation was made for hip and knee surgery but not for shoulder replacement due to the differences between shoulder replacement surgery and hip or knee replacement surgery. Unlike for hip and knee replacement, it is difficult to learn post-operative exercise routines prior to shoulder surgery as the exercises are unlikely to be possible before surgery. For similar reasons it is not possible to build up important muscle groups in the affected arm prior to shoulder surgery.

In current practice, preoperative rehabilitation is often provided in the form of a joint school for hip and knee replacements, which would be a one-off appointment providing education and exercises. There may however, be some resource impact for those areas where there is no joint school or pre-operative class in the form of additional staff time or venue location in order to give out the advice. This additional cost might be offset through a reduction in length of stay through patient adherence to preoperative rehabilitation advice.

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Appendices

Appendix B. Literature search strategies

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.63

For more detailed information, please see the Methodology Review.

B.1. Clinical search literature search strategy

Searches were constructed using a PICO framework where population (P) terms were combined with Intervention (I) and in some cases Comparison (C) terms. Outcomes (O) are rarely used in search strategies for interventions as these concepts may not be well described in title, abstract or indexes and therefore difficult to retrieve. Search filters were applied to the searches where appropriate.

Table 8. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

Cochrane Library (Wiley) search terms

B.2. Health Economics literature search strategy

Health economic evidence was identified by conducting a broad search relating to the joint replacement population in NHS Economic Evaluation Database (NHS EED – this ceased to be updated after March 2015) and the Health Technology Assessment database (HTA) with no date restrictions. NHS EED and HTA databases are hosted by the Centre for Research and Dissemination (CRD). Additional health economic searches were run in Medline and Embase.

Table 9. Database date parameters and filters used

Medline (Ovid) search terms

Embase (Ovid) search terms

NHS EED and HTA (CRD) search terms

Appendix D. Clinical evidence tables

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Appendix H. Health economic evidence tables

Download PDF (172K)

Appendix I. Excluded studies

Appendix J. Research recommendations

J.1. Preoperative rehabilitation

Research Question: What is the clinical and cost-effectiveness of a pre-operative rehabilitation given at least 2 months before hip, knee or shoulder replacement?

Why is this important:

People prior to hip, knee or shoulder replacement frequently present with a history of chronic joint pain, fear of movement and reduced physical function and independence with personal or extended activities of daily living. Following joint replacement, rehabilitation is aimed to address these to facilitate recovery. However, patient recovery may be enhanced both in speed and in outcome, through the provision of pre-operative rehabilitation interventions. These are aimed to increase physiological capability such as exercise tolerance and weight loss, pain management strategies and psychological readiness for surgery and subsequent recovery. Preoperative assessment of ADL performance and provision of advice and interventions aim to maintain and maximise function in the lead up to surgery. The current evidence-base on these interventions is limited in quality, with interventions largely assessed on exercise and education provision only. Future research in this area would provide clinicians and patients with a better understanding on what pre-operative interventions are indicated for improved post-operative outcomes, and which patients may be best directed to such interventions.

Criteria for selecting high-priority research recommendations

Final

Intervention evidence review underpinning recommendation 1.2.1 and the research recommendation in the NICE guideline

This evidence review was developed by the National Guideline Centre, hosted by the Royal College of Physicians

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian.

Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright © NICE 2020.
Bookshelf ID: NBK561392PMID: 32881450

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