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Assessment of outcomes of inpatient or clinic-based versus home-based rehabilitation after total knee arthroplasty: a systematic review and meta-analysis [with consumer summary]
Buhagiar MA, Naylor JM, Harris IA, Xuan W, Adie S, Lewin A
JAMA Network Open 2019 Apr 5;2(4):e192810
systematic review

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.

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