BACKGROUND: Contemporary strategies for prehabilitation and rehabilitation associated with total knee arthroplasty (TKA) surgery have focused on improving joint range-of-motion and function with less emphasis on neuromuscular performance beneficially affecting joint stability. Furthermore, prehabilitation protocols have been found to be too long and generic-in-effect to be considered suitable for routine clinical practice. METHODS: A pragmatic exploratory controlled trial was designed to investigate the efficacy of a novel, acute prehabilitative neuromuscular exercise-conditioning (APNEC) in patients electing TKA. Adults electing unilateral TKA were assessed and randomly allocated to exercise-conditioning (APNEC, n = 15) and usual care (Control, n = 14) from a specialised orthopaedic hospital, in the United Kingdom. APNEC prescribed nine stressful exercise-conditioning sessions for the knee extensors of the surgery leg, accrued over one week (3 sessions/week; 36 exercise repetitions in total; machine, gravity-loaded) and directly compared with usual care (no exercise). Prescribed exercise stress ranged between 60% to 100% of participant's daily voluntary strength capacity, encompassing purposefully brief muscular activations (<= 1.5 s). Baseline and follow-up indices of neuromuscular performance focusing on muscle activation capacity (electromechanical delay (EMD), rate of force development (RFD) and peak force (PF)) were measured ipsilaterally using dynamometry and concomitant surface electromyography (m. rectus femoris (RF) and m. vastus lateralis (VL)). RESULTS: Group mean ipsilateral knee extensor muscular activation capacity (EMDRF (F[3,57] = 53.5; p < 0.001); EMDVL (F[3,57] = 50.0; p < 0.001); RFD (F[3,57] = 10.5; p < 0.001)) and strength (PF (F[3,57] = 16.4; p < 0.001)) were significantly increased following APNEC (Cohen's d, 0.5 to 1.8; 15% to 36% versus baseline), but unchanged following no exercise control (per protocol, group by time interaction, factorial ANOVA, with repeated measures), with significant retention of gains at 1-week follow-up (p < 0.001). CONCLUSIONS: The exploratory APNEC protocol elicited significant and clinically-relevant improvement and its retention in neuromuscular performance in patients awaiting TKA. TRIAL REGISTRATION: ClinicalTrial.gov NCT03113032 (4/04/2017) and ISRCTN75779521 (3/5/2017).

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