Prehabilitation Improves Outcomes Among Patients Undergoing Orthopedic Surgery

Compared with standard care, prehabilitation improves preoperative function and strength among patients undergoing orthopedic surgery.

The use of prehabilitation was found to improve some outcomes for patients undergoing orthopedic surgery, according to findings of a systematic review and meta-analysis published in JAMA Network Open.

Researchers from Anglia Ruskin University in the UK searched publication databases through June 2022 for randomized clinical trials evaluating the effects of prehabilitation on orthopedic surgeries.

A total of 48 trials were included in the qualitative synthesis and 44 in the quantitative synthesis. All trials were published in 2000 or after.

The pooled study population included 3570 patients with a mean age of 64.1 (SD, 9.1) years; 61.5% were women. Most trials (58%) enrolled patients undergoing total knee replacement (TKR) alone and the remaining studies enrolled patients undergoing total hip replacement (THR), THR and TKR combined, lumbar surgery, anterior cruciate ligament reconstruction, and surgical intervention for femoroacetabular impingement syndrome.

The prehabilitation interventions included a range of exercises, such as strengthening, balance, and aquatic training. Some trials combined the exercises with preoperative education (21%), neuromuscular electrical stimulation (6%), and acupuncture (4%). Most interventions (81%) lasted at least 4 weeks, were delivered at least twice per week (77%), and were supervised (54%).

Prehabilitation programs with a combination of supervised and unsupervised sessions can be safely administered with minimal risks.

Prehabilitation was associated with reduced preoperative pain prior to THR (standardized mean difference [SMD], -0.47; 95% CI, -0.69 to -0.25), TKR (SMD, -0.58; 95% CI, -0.88 to -0.28), and lumbar surgery (mean difference [MD], -8.20; 95% CI, -8.85 to -7.55). Prehabilitation also improved health-related quality of life (HRQOL) among patients undergoing THR (MD, 7.35; 95% CI, 3.15-11.54) and lumbar surgery (SMD, 0.46; 95% CI, 0.13-0.78).

After surgery, prehabilitation was associated with improved back pain (MD, -5.93; 95% CI, -10.55 to -1.31) and function at 6 months (SMD, -2.35; 95% CI, -3.92 to -0.79) among patients who underwent lumbar surgery. Similarly, function was improved among patients who underwent TKR at 6 weeks (SMD, -0.51; 95% CI, -0.85 to -0.17) and 3 months (SMD, -0.29; 95% CI, -0.51 to -0.08) as well as for those who underwent THR at 3 months (SMD, -0.38; 95% CI, -0.62 to -0.14) and 12 months (SMD, -0.34; 95% CI, -0.65 to -0.02). Prehabilitation was also associated with improved flexor strength (SMD, 0.72; 95% CI, 0.23-1.21) and extensor strength (SMD, 0.45; 95% CI, 0.06-0.84) at 6 weeks after TKR.

Improvements in HRQOL postsurgery were associated with prehabilitation in the setting of TKR at 6 weeks (weighted mean difference [WMD], 5.66; 95% CI, 2.04-9.27) and 3 months (WMD, 1.89; 95% CI, 0.64-3.14).

“[P]rehabilitation was associated with moderate improvement in several preoperative outcomes […] among patients undergoing all orthopedic procedures and was also associated with a reduction in back pain among patients undergoing lumbar surgery. However, the evidence was inconsistent and the quality of evidence for postoperative outcomes was low to very low,” the study authors noted.

Overall, “Prehabilitation programs with a combination of supervised and unsupervised sessions can be safely administered with minimal risks,” they concluded.

Disclosures: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of author’s disclosures.


Punnoose A, Claydon-Mueller LS, Weiss O, Zhang J, Rushton A, Khanduja V. Prehabilitation for patients undergoing orthopedic surgery: a systematic review and meta-analysis. JAMA Netw Open. 2023;6(4):e238050. doi:10.1001/jamanetworkopen.2023.8050