Unsupervised Home Exercises Versus Formal Physical Therapy After Primary Total Hip Arthroplasty: A Systematic Review

Chaudhry YP, Hayes H, Wells Z, et al. Unsupervised home Exercises versus Formal Physical therapy after Primary total hip Arthroplasty: A Systematic review. Cureus. September 2022. doi:10.7759/cureus.29322

Link to Original Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9484297/

Key Points

- The study reviewed the use of formal physical therapy after total hip arthroplasty (THA) and compared it to unsupervised home exercise programs.

- The review included seven studies and found that formal PT did not show significant benefits over unsupervised home exercises in terms of short- and long-term changes in lower extremity strength, aerobic capacity, and quality of life scores.

- There was a small increase in short-term self-reported physical function scores favoring supervised exercise regimens, but no significant differences in long-term outcomes were found.

- The quality of evidence in the studies was rated as low due to biased outcome measurements and imprecision.

- The study highlighted the need to re-examine the routine use of formal PT following primary THA, considering the costs and potential drawbacks associated with supervised PT, such as accessibility barriers, pain, and increased readmission rates.

- While the results may suggest that formal PT may not warrant its cost, the study acknowledged the possibility that certain subgroups of patients may still benefit from supervised therapy.

Introduction

The introduction section of the research paper provides background information on the role of formal physical therapy (PT) after total hip arthroplasty (THA) and highlights the changing landscape of THA surgeries, which are now performed on younger, more active patients with improved pain control and rapid recovery. Despite these advancements, formal PT has remained a standard component for improving outcomes. The section discusses recent studies that question the benefits of formal PT compared to home-based unsupervised exercise programs, leading to a shift away from formal PT utilization without clear guidelines to identify which patients may benefit. The authors note potential benefits of reducing routine formal PT, such as alleviating financial and transportation burdens on patients and reducing episode-of-care costs, which may account up to 8% of the total costs for THA care. The primary aim of the review is to compare outcomes of THA patients undergoing formal supervised PT to those with unsupervised home exercise programs through a systematic review and meta-analysis of randomized controlled trials (RCTs). The review specifically focuses on assessing changes in lower extremity strength, aerobic capacity, and patient-reported physical outcome and quality of life scores at zero to six months and six months to one year.

Review

Inclusion criteria

The inclusion criteria for the systematic review and meta-analysis encompassed English-language randomized controlled trials (RCTs) that compared objective measures and patient-reported outcomes (PROs) of formal postoperative physical therapy (PT) or supervised exercise programs versus unsupervised home exercise interventions. The latter was defined as a home exercise program performed without direct health professional supervision, including written instructions, video programs, or phone applications. The intervention period considered was from hospital discharge to six months postoperatively. Studies exclusively comparing supervised or unsupervised cohorts, as well as those lacking clear delineation of the exercise interventions, were excluded. Additionally, RCTs involving preoperative exercise programs as the primary intervention were also excluded.

Search strategy and study screening

The research paper undertook a comprehensive search strategy with the support of an informationist to identify relevant literature. The search encompassed all published material from database inception to December 14, 2020, across multiple databases including PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, and ClinicalTrials.gov. To ensure thoroughness, a combination of MeSH and Emtree terms alongside free text was utilized to maximize search sensitivity. Initial screening of studies was conducted based on titles and abstracts, with pertinent studies progressing to full-text review. The screening process was independently carried out by two authors (YPC and HH), and any discrepancies were resolved through discussion, with the senior author (CAD) providing input when necessary.

Quality appraisal

The Cochrane Risk of Bias Tool 2.0 was used to evaluate potential bias in the included studies, considering specific domains such as randomization process, deviations from intended intervention, missing outcome data, outcome measurement, and selection of reported results. Each domain was assigned a risk score of "low," "some concern," or "high." This assessment was conducted for each outcome measurement included in the meta-analysis. Additionally, the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system was employed to appraise the quality of evidence in the meta-analysis, ensuring the reliability of the results.

Data extraction and statistical analysis

In the research paper, data extraction was conducted manually by three reviewers, capturing various descriptive variables such as journal, year, country of publication, number of cases, age, gender, body mass index, inclusion criteria, follow-up, type of intervention, time from discharge to intervention initiation, and intervention length. The outcomes of interest included changes in lower extremity strength (LES), aerobic capacity, and patient-reported physical function and quality of life (QoL). These outcomes were divided into short-term recovery (<6 months from surgery) and long-term recovery (≥6 months from surgery) windows. Changes from baseline values were collected as mean and standard deviation, with imputation performed when necessary. Only one outcome measure was included for studies with multiple measures in each category, and outcome measures were pooled for meta-analysis if at least three studies with reported results were available. All outcomes comprised continuous variables, and random effect models were used to calculate standardized mean differences (SMD) and 95% confidence intervals (CI). Heterogeneity was tested using the I2 statistic. Meta-analysis calculations and forest plots were generated using Review Manager Software Version 5.4.1.

Characteristics of included studies

A systematic search identified 4,358 citations, of which 2,592 studies were assessed for eligibility after removing duplicates. Fifty-seven studies underwent full-text review, with ultimately seven studies (398 cases) meeting the inclusion criteria. The included studies were conducted within the last ten years, with the exception of one conducted in 2008. Three of the seven studies initiated intervention programs upon discharge, two in the first week after surgery, one at six weeks postoperatively, and one at 12 weeks postoperatively. The average duration of the intervention programs was 8.0 ± 2.8 weeks. Six studies reported short-term outcomes, while five reported long-term outcomes. Additionally, isometric muscle strength and gait speed were assessed at four weeks postoperatively. The characteristics of the included studies are summarized in tables within the paper.

Short-Term Outcomes

The short-term outcomes of supervised physical therapy versus unsupervised home exercise programs following total hip arthroplasty were investigated in six studies. In five out of six studies, both interventions were found to be similar in terms of short-term lower extremity strength and aerobic capacity, with no statistically significant differences between the two approaches. One study favored supervised cohort, although it was unable to determine if the difference was clinically significant. No significant difference was found in short-term aerobic capacity and QoL scores. However, supervised physical therapy was associated with improved self-reported physical function outcome scores compared to unsupervised home exercise, although the effect size was considered small. Additionally, there were no differences in short-term quality of life scores between the two cohorts.

Long-Term Outcomes

In terms of long-term outcomes, no differences were identified between the supervised and unsupervised cohorts. Both groups showed similar outcomes in terms of long-term lower extremity strength, patient-reported physical outcome scores, and quality of life scores.

Discussion

The meta-analysis discussed in the paper questions the routine use of formal physical therapy (PT) for all primary total hip arthroplasty (THA) patients. The study found no significant differences in short- and long-term changes in lower extremity strength, aerobic capacity, or self-reported quality of life scores between supervised PT and unsupervised home exercise programs, except for a small increase in short-term self-reported physical function scores. Other reviews have yielded mixed results, with some indicating potential benefits of formal PT on physical function scores and hip abduction strength, but without clear differentiation between short- and long-term follow-up points. The study's distinct feature is the clear inclusion criteria for the unsupervised home exercise groups, excluding studies with no specified intervention for the control group. The discussion also highlights the drawbacks of formal PT, including cost, scheduling, pain, and higher readmission rates, as well as the substantial post-discharge costs incurred. The analysis emphasizes that the observed short-term differences were largely driven by a single study, and the overall results are limited by the number and quality of the included studies. The study recommends re-examining the routine use of PT following primary THA, especially considering the substantial post-discharge costs and potential bias in patient-reported outcomes in supervised PT cohorts. However, the study acknowledges limitations in exercise regimen heterogeneity, patient population selection, and potential crossover rates, while acknowledging strengths such as narrow inclusion criteria for unsupervised cohorts.

Conclusions

The conclusion of the research paper highlights that despite the historical emphasis on the importance of formal physical therapy (PT) after primary total hip arthroplasty (THA), the currently available literature does not demonstrate a significant benefit for formal PT over unsupervised home exercise programs. It suggests that there may be no significant difference in outcomes between formal PT and unsupervised home exercise for most patients undergoing primary THA. However, the conclusion also recognizes the possibility that certain subgroups of deconditioned patients may benefit from supervised therapy.

The findings of this review may help providers in educating their patients on whether to pursue formal PT programs postoperatively. The review indicates that aside from a short-term increase in self-reported physical outcome scores, there is little demonstrated benefit of formal PT over unsupervised home exercise programs. Therefore, the routine use of formal PT may not warrant its cost.

Overall, the conclusion suggests that there may be limited benefit to routine formal PT for all patients undergoing primary THA, as the currently available evidence does not support its significant advantage over unsupervised home exercise programs. However, it also acknowledges the potential benefits for specific patient subgroups and emphasizes the importance of considering individual patient characteristics and needs when making decisions about postoperative physical therapy.