|Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials
|Minns Lowe CJ, Barker KL, Dewey ME, Sackley CM
This review concluded that there was insufficient evidence to established the effectiveness of physiotherapy exercise following primary hip replacement for osteoarthritis. The authors' cautious conclusions were supported by the results, but should be interpreted with some caution due to questions relating to the analysis.
To evaluate the effectiveness of physiotherapy exercise after discharge following elective primary total hip arthroplasty.
AMED, CINAHL, EMBASE, King's Fund database, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, DARE, PEDro and Department of Health National Research Register were searched from inception to April 2007. Search strategies were reported. Two relevant journals and conference proceedings in an additional journal were handsearched from 1985 to 2006/2007. Reference lists of retrieved studies were screened. No language restrictions were applied.
Prospective clinical trials that compared physiotherapy exercise rehabilitation against usual care or alternative physiotherapy intervention in patients who were discharged from hospital following total hip replacement surgery for osteoarthritis were eligible for inclusion. Physiotherapy and exercise were broadly defined to include any exercises or exercise programme advised or provided by physiotherapists/physical therapists. Programmes could occur in the outpatient community or home setting. Studies in which the intervention consisted of an electrical adjunct to physiotherapy were excluded.
Outcomes assessed by the included studies were measures of functional activities of daily living, walking, self-report measures of quality of life, muscle strength and range of hip joint motion. Outcomes were assessed using a variety of measures. Outpatient physiotherapy included in the interventions consisted of aerobic dance routine, individualised physiotherapy treatment, group training, supervised strengthening sessions, supervised exercising sessions and home exercises. Interventions started from straight after surgery to up to several years postoperatively. Duration of intervention ranged from five weeks to four months. Frequency of intervention ranged from daily to once per week. One trial followed patients up for six months post-intervention; all other trials followed up immediately post intervention.
Two reviewers assessed and agreed on studies for inclusion.
Assessment of study quality
Two reviewers independently assessed study quality according to the following criteria: study rationale, eligibility criteria, recruitment methods, setting and study location, intervention, objectives/hypotheses, defined outcome measures, quality enhancers, sample size determination, randomisation, randomisation sequence generation, allocation concealment, randomisation implementation methods, blinding of participants, administrators and outcome assessors, statistical methods, participant flow, recruitment and follow-up, baseline demographics, numbers analysed and use of intention to treat, summary of results, estimated effect sizes, precision, results for each outcome, ancillary analyses, adverse events, interpretation, generalisability and results placed in context. Studies were graded as yes, no, unclear or partial for each item. Disagreements were resolved through consensus.
Two reviewers independently extracted data and calculated standardised effect sizes.
Methods of synthesis
Summary standardised effect sizes were estimated using a fixed-effect meta-analysis for outcomes evaluated in sufficient studies. The authors stated that weighted mean differences (WMD) were calculated for walking speed. Where studies used multiple measures of walking speed, analyses were performed using correlations of 0.2, 0.5 and 0.8, with 0.8 being used for the main analysis.
Results of the review
Eight studies were included in the review (n=282, range 20 to 58). Study quality was generally poor. Only three were randomised and in one of these sequence generation was not adequate. None of the randomised trials adequately concealed treatment allocation. Only one study blinded participants, one partially blinded intervention administerers and three blinded outcome assessors.
Self report measures of function (five trials, n=190): Three studies showed no significant differences between treatment groups and two trials showed significant within group differences for the treatment arm.
Walking (six trials, n=212): One trial reported a statistically significant improvement in walking speed from baseline to post-intervention in intervention group, but not in the control group. One trial reported differences between groups in walking stamina, but the statistical significant of this was not reported. Two trials found no significant differences between groups. Two trials reported significant improvements within the intervention group, but not when compared to controls. Meta-analysis based on four trials showed a pooled standardised effect size of 0.42 (95% CI 0.07 to 0.77), which indicated a beneficial effect of the intervention on walking speed.
Range of joint motion (four trials, n=134): None of the studies reported significant beneficial effects of the intervention.
Muscle strength (six trials, n=207): Three studies reported no difference between treatment groups, two reported a significant improvement in treatment group from baseline and one reported a significant improvement in treatment compared to control group.
Quality of life (one trial, n=55): The study reported no significant differences between groups.
There was insufficient evidence to establish effectiveness of physiotherapy exercise following primary hip replacement for osteoarthritis. Further well-designed trials were required to determine the value of post-discharge exercise following this increasingly common surgical procedure.
The review addressed a focused question supported by clearly defined inclusion criteria. An extensive literature search was conducted and some attempts to locate unpublished studies and avoid language bias were made. Appropriate steps were taken to minimise bias and errors at all stages of the review process. The detailed quality assessment used a long list of items that included relevant sources of bias. However, additional details on how items were rated would have been helpful and study quality was not adequately considered in the synthesis of results. The reporting of the review was somewhat difficult to follow and at times appeared to present contradictory information. For example, the authors stated that weighted mean differences for walking speed were estimated whereas results presented were for summary standardised effect sizes and the flow diagram suggested that only two studies contributed to the meta-analysis whereas four trials contributed to the meta-analyses reported in the results. The synthesis appeared appropriate, but it was unclear why selected studies contributed to the two meta-analyses reported instead of all studies that assessed these outcomes. The authors' cautious conclusions were supported by the results, but should be interpreted with some caution due to questions relating to the analysis.
Implications of the review for practice and research
Practice: The authors did not state any implications for practice.
Research: The authors stated that there was a need for well-conducted clinical trials investigating the effectiveness of physiotherapy exercise interventions following discharge after elective primary total hip replacement surgery.
Nursing and Allied Health Professional Researcher Development Award from NIHR. Primary Care Career Scientist Award from the NIHR.
Minns Lowe CJ, Barker KL, Dewey ME, Sackley CM. Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials. BMC Musculoskeletal Disorders 2009; 10:98
Subject indexing assigned by NLM
Activities of Daily Living; Arthroplasty, Replacement, Hip; Clinical Trials as Topic; Evidence-Based Medicine; Exercise Therapy; Hip Joint /physiopathology /surgery; Humans; Muscle Strength; Osteoarthritis, Hip /physiopathology /surgery /therapy; Patient Discharge; Quality of Life; Range of Motion, Articular; Recovery of Function; Treatment Outcome; Walking
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.