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Abstract
Objective Nearly 100 000 primary total knee replacements (TKR) are performed in the UK annually. The primary aim of TKR is pain relief, but 10%–34% of patients report chronic pain. The aim of this systematic review was to evaluate the effectiveness of presurgical interventions in preventing chronic pain after TKR.
Design MEDLINE, Embase, CINAHL, The Cochrane Library and PsycINFO were searched from inception to December 2018. Screening and data extraction were performed by two authors. Meta-analysis was conducted using a random effects model. Risk of bias was assessed using the Cochrane tool and quality of evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation.
Primary and secondary outcomes Pain at 6 months or longer; adverse events.
Interventions Presurgical interventions aimed at improving TKR outcomes.
Results Eight randomised controlled trials (RCTs) with data from 960 participants were included. The studies involved nine eligible comparisons. We found moderate-quality evidence of no effect of exercise programmes on chronic pain after TKR, based on a meta-analysis of 6 interventions with 229 participants (standardised mean difference 0.20, 95% CI −0.06 to 0.47, I2=0%). Sensitivity analysis restricted to studies at overall low risk of bias confirmed findings. Another RCT of exercise with no data available for meta-analysis showed no benefit. Studies evaluating combined exercise and education intervention (n=1) and education alone (n=1) suggested similar findings. Adverse event data were reported by most studies, but events were too few to draw conclusions.
Conclusions We found low to moderate-quality evidence to suggest that neither preoperative exercise, education nor a combination of both is effective in preventing chronic pain after TKR. This review also identified a lack of evaluations of other preoperative interventions, such as multimodal pain management, which may improve long-term pain outcomes after TKR.
PROSPERO registration number CRD42017041382.
- chronic post-surgical pain
- prevention
- systematic review
- total knee replacement
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Footnotes
Contributors All authors contributed to the concept and design of the study. JD, ADB and VW contributed to the acquisition and analysis of data. JD and ADB drafted the article and VW, RG-H and AWB revised it critically for important intellectual content. JD and ADB take responsibility for the integrity of the work as a whole, from inception to finished article.
Funding This study is funded by the National Institute for Health Research (NIHR) [NIHR Programme Grant for Applied Research (Grant Reference Number RP-PG-0613–20001)]. This study was also supported by the NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.
Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funder had no involvement in the study design, data collection, data analysis, interpretation of data or writing of the manuscript.
Competing interests Outside of this work, VW and AWB are co-applicants on an institutional grant from Stryker for a study evaluating the outcomes of the Triathlon knee replacement.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available. All data relevant to the study are included in the article or uploaded as supplementary information.