Prehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis
Open accessAbstract
Importance: Prehabilitation programs for patients undergoing orthopedic surgery have been gaining popularity in recent years. However, the current literature has produced varying results. Objective: To evaluate whether prehabilitation is associated with improved preoperative and postoperative outcomes compared with usual care for patients undergoing orthopedic surgery. Data Sources: Bibliographic databases (MEDLINE, CINAHL [Cumulative Index to Nursing and Allied Health Literature], AMED [Allied and Complementary Medicine], Embase, PEDRO [Physiotherapy Evidence Database], and Cochrane Central Register of Controlled Trials) were searched for published trials, and the Institute for Scientific Information Web of Science, System for Information on Grey Literature in Europe, and European clinical trials registry were searched for unpublished trials from January 1, 2000, to June 30, 2022. Study Selection: Randomized clinical trials (RCTs) comparing prehabilitation with standard care for any orthopedic surgical procedure were included. Data Extraction and Synthesis: Two independent reviewers screened trials. Data were pooled using a random-effects model. Recommendations were determined using the Grading of Recommendations Assessment, Development and Evaluation system and the study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Main Outcomes and Measures: Pain, function, muscle strength, and health-related quality of life (HRQOL). Results: Forty-eight unique trials involving 3570 unique participants (2196 women [61.5%]; mean [SD] age, 64.1 [9.1] years) were analyzed. Preoperatively, moderate-certainty evidence favoring prehabilitation was reported for patients undergoing total knee replacement (TKR) for function (standardized mean difference [SMD], −0.70 [95% CI, −1.08 to −0.32]) and muscle strength and flexion (SMD, 1.00 [95% CI, 0.23-1.77]) and for patients undergoing total hip replacement (THR) for HRQOL on the 36-item Short Form Health Survey (weighted mean difference [WMD], 7.35 [95% CI, 3.15-11.54]) and muscle strength and abduction (SMD, 1.03 [95% CI, 0.03-2.02]). High-certainty evidence was reported for patients undergoing lumbar surgery for back pain (WMD, –8.20 [95% CI, −8.85 to −7.55]) and moderate-certainty evidence for HRQOL (SMD, 0.46 [95% CI, 0.13-0.78]). Postoperatively, moderate-certainty evidence favoring prehabilitation was reported for function at 6 weeks in patients undergoing TKR (SMD, −0.51 [95% CI, −0.85 to −0.17]) and at 6 months in those undergoing lumbar surgery (SMD, −2.35 [95% CI, −3.92 to −0.79]). Other differences in outcomes favoring prehabilitation were of low to very low quality of evidence. Conclusions and Relevance: In this systematic review and meta-analysis of RCTs, moderate-certainty evidence supported prehabilitation over usual care in improving preoperative function and strength in TKR and HRQOL and muscle strength in THR, high-certainty evidence in reducing back pain, and moderate-certainty evidence in improving HRQOL in lumbar surgery. Postoperatively, moderate-certainty evidence supported prehabilitation for function following TKR at 6 weeks and lumbar surgery at 6 months. Prehabilitation showed promising results for other outcomes, although high risk of bias and heterogeneity affected overall quality of evidence. Additional RCTs with a low risk of bias investigating preoperative and postoperative outcomes for all orthopedic surgical procedures are required.
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Many reviews, including an umbrella review of 55 unique systematic reviews, suggest that prehabilitation may have protective effects in reducing complications, length of stay, and improving functional recovery.
“Many reviews,11 12 13 14 including an umbrella review that synthesised 55 unique systematic reviews,1 suggest that prehabilitation may have protective effects in reducing complications, length of stay, and improving functional recovery.”
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Flagged first, then by citations
Research works printed but not linked: 1
- [37]The effect of various strength training protocols in ACL reconstructed participants. ClinicalTrials.gov identifier: NCT03364647. Accessed September 28, 2021. https://clinicaltrials.gov/ct2/show/NCT03364647
Cited by
Sorted by citations
McIsaac, D. I., Kidd, G., Gillis, C., Branje, K., Al-Bayati, M., Baxi, A., Grudzinski, A. L., Boland, L., Veroniki, A.-A., Wolfe, D., et al. (2025) · BMJ · doi:10.1136/bmj-2024-081164 · Cited by 168 · see citing works
- Authors
- Punnoose, A., Claydon-Mueller, L. S., Weiss, O., Zhang, J., Rushton, A., & Khanduja, V.
- Affiliations
- National Health Service (GB)
- School of Allied Health, Anglia Ruskin University, Chelmsford and Cambridge, United Kingdom
- Meir Medical Center (IL)
- Anglia Ruskin University (GB)
- Western University (CA)
- Addenbrooke's Hospital (GB)
- Corresponding author
- Punnoose, Anuj
- Venue
- JAMA Network Open
- Publisher
- American Medical Association (AMA)
- Published
- 2023-04-13
- Volume
- 6
- Issue
- 4
- Pages
- e238050
- ISSN
- 2574-3805 (ISSN-L)
- PMC
- PMC10102876
- OpenAlex
- W4365443228
- Cited by
- 219
- References
- 118
- Citations by year
- 2026: 76 · 2025: 69 · 2024: 62 · 2023: 12
- FWCI
- 14.15
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JAMA Network Open (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Anglia Ruskin Research Online (Anglia Ruskin University) (submittedVersion)
- Figshare (submittedVersion, cc-by)
- Funders
- National Institute for Health and Care Research (NIHR302117)
- Topics
- Health Sciences › Medicine › Surgery › Enhanced Recovery After Surgery
- Health Sciences › Medicine › Surgery › Total Knee Arthroplasty Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac, Anesthesia and Surgical Outcomes
- Keywords
- prehabilitation, orthopedic surgery, total knee arthroplasty, total hip arthroplasty, lumbar spine surgery, back pain, postoperative pain, postoperative function, muscle strength, health-related quality of life, usual care comparison, postoperative complications, length of hospital stay, patient-reported outcomes, knee flexion, hip abduction, lumbar flexion
- MeSH terms
- Preoperative Exercise, Europe, Female, Humans, Middle Aged, Quality of Life, Orthopedic Procedures
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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