Effect of Prehabilitation Before Total Knee Replacement for Knee Osteoarthritis on Functional Outcomes

Key Points Question What is the effectiveness of multidisciplinary prehabilitation compared with usual care before total knee replacement for knee osteoarthritis in terms of functional independence and activity limitations after surgery? Findings In this randomized clinical trial of 262 participants, multidisciplinary prehabilitation before total knee replacement for knee osteoarthritis did not improve short-term functional independence or reduce midterm activity limitations after surgery. Meaning Trial findings question the usefulness of prehabilitation before total knee replacement to improve functional outcomes.

eAppendix 1. Substantial changes to methods after trial commencement and the reasons for those changes.
Amendment 1: 06/21/2012 -Modification of the study outline in order to adapt to the procedures of all the participating centers. -Visits at 3 and 12 months postoperatively. -Contact by phone or by mail 6 weeks, 4, 5 and 6 months postoperatively. Amendment 2: 04/15/2014 -Update of the reporting circuit for serious adverse events. -Extension of the 12-month inclusion period in order to include the number of patients initially planned and necessary to assess this intervention and its medico-economic value. Amendment 3: 05/04/2015 -Request for an extension of the duration of inclusions by 12 months.
-Modification of the study plan concerning the modalities of the visits at 3 and 12 months: concerning the follow-up at 3 and 12 months, and taking into account the data that it is planned to collect (selfassessment notebooks), the The choice will be left to the patient to come to the delivery of the selfquestionnaires completed during a consultation, or to return the completed self-questionnaires by mail (T envelope) or even to complete the self-questionnaires assisted by a technician clinical studies during a phone call. Amendment 4: 04/18/2017 -Modification of the investigator-coordinator, Prof. Francois RANNOU replaces Prof. Serge POIRAUDEAU (deceased) Amendment 5: 02/28/2018 -Extension of the total duration of the study by 1 month to be able to follow up on the last patient included. Amendment 6: 03/26/2018 -Added precision on the version of the EQ-5D quality of life questionnaire used: this is the EQ-5D-3L version used in the study. -Addition of a clarification concerning the main endpoint (capacity at discharge from the surgical department): the percentage of patients achieving independence on the day of discharge from the orthopedic department will be the main outcome measure. This is a more precise description of the primary outcome.
-Addition of details on the secondary objectives and the efficacy and safety criteria: this is a more precise description of the treatment efficacy and safety criteria. During the 1st session, patients were taught a home exercise program to do until knee surgery.

I. Muscle strengthening
• Quadriceps ▪ Sitting on a chair, back straight, the heel resting on a step.

▪
Raise your foot and extend your knee, ankle lifted.
▪ Hold the position for 6 seconds. Repeat 10 times. •

Lateral knee stabilisers
Sitting on a chair, back straight. Place a stool in front of you.
▪ Place your feet on both sides of the legs of the stool. Use the medial border of the feet to tighten the legs, don't move your knees. ▪ Do the same exercise but with your feet inside of the stool. Use the lateral border of the feet to spread the legs of the stool, don't move your knees.
▪ Hold the position for 6 seconds. Repeat 10 times.

• Hamstrings
▪ Sitting on a chair, back straight, knees slightly flexed, legs crossed at the ankles level ▪ Push the front leg back against the rear leg which resists to the movement.
▪ Hold the position for 6 seconds. Repeat 10 times.

Rectus Femoris
▪ Standing on a foot, looking ahead, holding a piece of furniture for balance. Contract abdominal and buttock muscles to immobilize your pelvis. Grab your ankle with your hand (or using a scarf if you are unable to hold your ankle with the hand). Pull knee back without moving your pelvis and your lower back. Hold the position for 20 seconds, repeat 2 times, on each side (if needed).
• Hamstrings ▪ Lying on your back, knees bent, feet on the floor. Raise your leg (holding the thigh with both hands), extend the knee by pushing the heel towards the ceiling. Hold the position for 20 seconds, repeat 2 times, on each side (if needed). •

Hamstrings and Triceps Surae
▪ Standing, holding a piece of furniture for balance. Place one foot (lifted so that it leans on the heel) on a step, feet and pelvis are facing the same direction.
▪ Lean forward to flex the trunk from the hip, keep your back straight, your knee extended and your ankle lifted. Hold 20 seconds, repeat 2 times, on each side (if needed).

III. Knee posture, balance and proprioception:
• Knee posture to prevent or correct a lack of knee extension ▪ Sitting on a chair, back straight, one foot, leaning by the heel on a stool, knee in the air.
▪ Hold the posture for 20 minutes trying to extend the knee as far as possible.
▪ If you feel your knee hot and/or painful, you can put a cold pack (wrapped in a cloth) on the knee during the posture.
• Improving balance ▪ Standing, in front of a piece of furniture (for sake of safety), one foot on a cushion, knee slightly bent.
▪ Raise the other foot and try to hold your balance for a few seconds (without holding the piece of furniture).
▪ NB: if you consider this exercise too difficult, do it without the cushion (i.e. foot on the floor) • Knee mobility Material: a skateboard or a ball ▪ Sitting on a stool, back straight, one foot on a ball.
▪ Extend and flex your knee as far as possible by rolling the ball forward and backward under your foot (in knee extension, only your heel will be in contact with the ball). ▪ Hold the position (maximal knee flexion/ extension) for 20 seconds, repeat 2 times, on each side (if needed).
2 nd to 4 th sessions: those sessions were dedicated to learning transfers technics, to use crutches to walk and to go up and down stairs. It was a preparation to the post-operative period.

I. Learning how to transfer
The physiotherapist shows each activity and then the patient practices it.

A. Supine to sitting transfer
The patient is in supine position in a medical bed.
The patient uses his contralateral leg to support his operated one.
▪ Using the over bed pole hoist, ▪ The patient moves as close as possible to the edge of the bed.
▪ Then with the help of both arms, rotates to sit down.
First leaning on his contralateral leg, the patient moves the two crutches down on the first step, then he moves the operated leg and finally, pushing on his crutches, he moves the contralateral leg on the same step.
The patient practices until he is able to move without or with few instructions.

III. Revision the home exercises program
The last session was dedicated to the revision of the home exercises program. In addition regular aerobic activity (walking, cycling on training bike…) was recommended to patient.