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    Original Investigation
    Physical Medicine and Rehabilitation
    April 26, 2019

    Assessment of Outcomes of Inpatient or Clinic-Based vs Home-Based Rehabilitation After Total Knee Arthroplasty: A Systematic Review and Meta-analysis

    Author Affiliations
    • 1Catholic Diocese of Parramatta, Parramatta, Australia
    • 2South West Sydney Clinical School, University of New South Wales, Sydney, Australia
    • 3Whitlam Orthopaedic Research Centre, Liverpool, Australia
    • 4South Western Sydney Local Health District, Sydney, Australia
    • 5Ingham Institute of Applied Medical Research, Liverpool, Australia
    JAMA Netw Open. 2019;2(4):e192810. doi:10.1001/jamanetworkopen.2019.2810
    Key Points español 中文 (chinese)

    Question  Is inpatient or clinic-based rehabilitation associated with superior outcomes after total knee arthroplasty compared with home programs?

    Findings  This systematic review and meta-analysis included 5 unique studies involving 752 unique participants comparing clinic- and home-based rehabilitation and 1 study comparing inpatient rehabilitation with a home-based program. Based on low- to moderate-quality evidence, no associations between settings, no clinically important differences for mobility or patient-reported pain and function at 10 and 52 postoperative weeks, and no significant differences in quality of life or range of motion were found.

    Meaning  For adults who underwent total knee arthroplasty, clinic or inpatient vs home-based rehabilitation appeared to offer no clinically important advantages.


    Importance  Recent publication of the largest trials to date investigating rehabilitation after total knee arthroplasty (TKA) necessitate an updated evidence review.

    Objective  To determine whether inpatient or clinic-based rehabilitation is associated with superior function and pain outcomes after TKA compared with any home-based program.

    Data Sources  MEDLINE, Embase, CINAHL, and PubMed were searched from inception to November 5, 2018. Search terms included knee arthroplasty, randomized controlled trial, physiotherapy, and rehabilitation.

    Study Selection  Published randomized clinical trials of adults who underwent primary unilateral TKA and commenced rehabilitation within 6 postoperative weeks in which those receiving postacute inpatient or clinic-based rehabilitation were compared with those receiving a home-based program.

    Data Extraction and Synthesis  Two reviewers extracted data independently and assessed data quality and validity according to the PRISMA guidelines. Data were pooled using a random-effects model. Data were analyzed from June 1, 2015, through June 4, 2018.

    Main Outcomes and Measures  Primary outcomes were mobility (6-minute walk test [6MWT]) and patient-reported pain and function (Oxford knee score [OKS] or Western Ontario and McMaster Universities Osteoarthritis Index) reported at 10 to 12 postoperative weeks. The GRADE assessment (Grading of Recommendations, Assessment, Development, and Evaluation) was applied to the primary outcomes.

    Results  Five unique studies involving 752 unique participants (451 [60%] female; mean [SD] age, 68.3 [8.5] years) compared clinic- and home-based rehabilitation, and 1 study involving 165 participants (112 [68%] female; mean [SD] age, 66.9 [8.0] years) compared inpatient and home-based rehabilitation. Low-quality evidence showed no clinically important difference between clinic- and home-based programs for mobility at 10 weeks (6MWT favoring home program; mean difference [MD], −11.89 m [95% CI, −35.94 to 12.16 m]) and 52 weeks (6MWT favoring home program; MD, −25.37 m [95% CI, −47.41 to −3.32 m]). Moderate-quality evidence showed no clinically important difference between clinic- and home-based programs for patient-reported pain and function at 10 weeks (OKS MD, −0.15 [95% CI, −0.35 to 0.05]) and 52 weeks (OKS MD, 0.10 [95% CI, −0.14 to 0.34]).

    Conclusions and Relevance  Based on low- to moderate-quality evidence, no superiority of clinic-based or inpatient programs compared with home-based programs was found in the early subacute period after TKA. This evidence suggests that home-based rehabilitation is an appropriate first line of therapy after uncomplicated TKA for patients with adequate social supports.