The Physician and Sportsmedicine

ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsm20

Is it necessary to perform prehabilitation exercise

for patients undergoing total knee arthroplasty:
meta-analysis of randomized controlled trials

Huifen Chen, Suyun Li, Tingyu Ruan, Li Liu & Li Fang

To cite this article: Huifen Chen, Suyun Li, Tingyu Ruan, Li Liu & Li Fang (2017): Is it
necessary to perform prehabilitation exercise for patients undergoing total knee arthroplasty:
meta-analysis of randomized controlled trials, The Physician and Sportsmedicine, DOI:
10.1080/00913847.2018.1403274

To link to this article: http://dx.doi.org/10.1080/00913847.2018.1403274

Accepted author version posted online: 10

Nov 2017.

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 Is it necessary to perform prehabilitation exercise for patients undergoing total

knee arthroplasty: meta-analysis of randomized controlled trials

Huifen Chen1, Suyun Li1, Tingyu Ruan1, Li Liu1, Li Fang1

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Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong

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University of Science and Technology, Wuhan 430022, China

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Corresponding author: Huifen Chen, E-mail: xhgk545@163.com. Telephone: +0086

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13886179668. Fax: +0086 027-85726547.

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Abstract
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Objectives: This study was designed to test whether it is necessary to perform

prehabilitation exercise for patients undergoing total knee arthroplasty (TKA).

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Methods: Literatures were identified from Pubmed, Clinicaltrials, Cochrane library,

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and SpringerLink. All studies that compared a prehabilitation exercise group with

control group before TKA were included. The primary outcome was length of hospital
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stay. Secondary outcomes were quadriceps strength and functional ability in short
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term (1.5 to 3 months) after TKA.

Results: There was significant difference in the length of hospital stay, knee range of

motion (ROM) and sit-to-stand test (P＜0.05). No statistical differences were found in

quadriceps strength, 6-minute walk, ROM, knee extension, knee flexion, WOMAC

pain, WOMAC function, WOMAC stiffness between the two groups in short term
 after TKA (P＞.05).

Conclusions: Our meta-analysis found that prehabilitation exercise was effective in

reducing length of hospital stay. Importantly, it was an effective method for

improving knee ROM and sit-to-stand test after TKA. However, there was no effect of

prehabilitation exercise on the improvement of quadriceps strength, 6-minute walk,

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pain and functional recovery following TKA.

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Keywords: prehabilitation exercise; total knee arthroplasty; randomized controlled
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trials; meta-analysis

Introduction
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Osteoarthritis (OA) is one of the common joint disorder and the prevalence of OA is
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rising. When suffering from severe knee OA, total knee arthroplasty (TKA) is a

recommended treatment option which is helpful to relieve the pain and improve the
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function of knee1,2. However, an increasing number of studies3 reported that some

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patients suffering from functional impairments and strength deficits after TKA.
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Exercise has been recommended by European League Against Rheumatism and

studies as an effective treatment option for OA patients to decrease the pain and

improve the function of knee4,5. In the same time, exercise was also applied to those

patients who are waiting for TKA6. Swank7 reported that short term (4-8 weeks)

prehabilitation before TKA was effective in increasing strength and function in older

adults with severe OA. Although some studies8,9 reported that prehabilitation
 exercise was effective in improving postoperative strength and mobility for patients

undergoing TKA, other studies10,11 found that it was no effect on the functional

recovery of knee. .

Therefore, this meta-analysis was designed to compare the effectiveness of the

prehabilitation exercise with usual care on patients by evaluating the length of

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hospital stay, quadriceps strength and functional recovery following TKA.

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Materials and Methods
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Search strategy an
Studies were identified through a computerized search in Pubmed, ClinicalTrials,

Cochrane library, and SpringerLink from January 1990 to June 2017. Following search
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terms were used: total knee arthroplasty OR total knee replacement OR TKA OR TKR
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AND physiotherapy OR physical therapy OR exercise OR training OR prehabilitation

AND preoperative.
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Inclusion and exclusion criteria

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Inclusion criteria: (1) randomized controlled studies; (2) comparison of pre-operative

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exercise group with control group; (3) the articles were restricted to English language;

(4) patients older than 18 years; (5) the clinical outcomes that include the length of

hospital stay and/or functional recovery.

Exclusion criteria: (1) Articles that include the same data set; (2) No outcomes of

interest were reported; (3) Type of trials as “case report”, “letters” and
 “commentary”.

Data Extraction

Two authors independently collected data from the included studies. Disagreement

between the authors was resolved by discussion with a third investigator. The

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following data were extracted: demographic data of patients including age, gender,

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location of study, intervention, length of hospital stay, pain scores, function scores. If

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the required information was obscure or missing, we attempted to contact the article
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authors to obtain further details.

Quality and risk of bias assessments

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The modified Jadad scale was used to assess the quality of the RCTs, including
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randomization, blinding, withdraws and dropouts, inclusion and exclusion criteria

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and adverse reactions. Low quality studies were reflected by scores of 0-3, whereas

high quality studies were indicated by scores of 4-7. The risk of bias of each study
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was assessed according to the Cochrane Handbook for Systematic Reviews of

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Interventions guideline. The following items were assessed by two authors:

allocation sequence generation; allocation concealment; blinding of subjects, doctors,

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and outcome assessors; selective outcome reporting and other bias.

Statistical analysis

Review Manager Statistical software (version 5.3) was used to calculate the effect

sizes of each study. Changes from baseline were pooled to compare outcomes

between groups. For all comparisons, mean difference and 95% CI were calculated
 for continuous outcomes. Heterogeneity was tested using the chi-squared test and I2

statistic. An I2 statistic value of >75% was considered to indicate substantial

heterogeneity. Random effect model was used when there was statistical evidence of

heterogeneity. P<0.05 was set as statistical significance.

Results

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Literature search results and study characteristics

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The identification of studies, their inclusion and exclusion were shown in Figure 1. An

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electronic search yielded 224 potentially relevant studies. This eventually resulted in
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16 studies that were included in this meta-analysis study.

The details of study characteristics and quality of the studies were shown in Table 1
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and Table 2. There were 612 patients in the prehabilitation group and 612 patients in
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the control group. There were 14 RCTs with high quality and 2 RCTs with low quality.

Risk of bias assessment

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The risk of bias of each study were shown in Fig.2. Sequence generation and
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allocation concealment were judged as low risks in 13 trials and 10 trials, respectively.
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Blinding of outcome assessors were judged as low risks in 11 trials.

Length of hospital stay and quadriceps strength

Of the 16 trials, five trials10,12-15 reported the data of length of hospital stay and three

trials8,10,16 reported the data of quadriceps strength. The prehabilitation group

showed a shorter length of hospital stay when compared with the control group
 (I2=45%, MD -0.8, 95% Cl -1.11 to -0.48, P＜0.05). (Fig.3) There was no significant

difference among the two groups in terms of quadriceps strength (I2=69%, MD 0.2,

95% Cl -0.25 to 0.64, P＞0.05). (Fig.4)

Sit-to-Stand and 6-minute walk

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Of the 16 trials, two trials9,17 reported the data of sit-to-stand and three trials9,11,17

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reported the data of 6-minute walk. The prehabilitation group showed a better

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sit-to-stand result than the control group(I2=60%, MD 1.68, 95% Cl 1.25 to 2.1, P＜
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0.05). (Fig.5) There was no significant difference among the two group in 6-minute

walk test (I2=32%, MD -19.55, 95% Cl -42.37 to 3.28, P＞0.05). (Fig. 6)

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Knee range of motion (ROM), extension and flexion
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A total of three trials10,16,18 provided data of knee ROM and five trials11,16,17,19,20
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provided data of knee extension and knee flexion. There was significant difference

between the groups in terms of knee ROM (I2=22, MD 3.62, 95% Cl 0.05 to 7.19, P＜
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0.05).(Fig.7) Besides, there was no significant difference among the two groups in
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terms of knee extension (I2=0, MD -0.1, 95% Cl -0.62 to 0.82, P＞0.05) and knee

flexion (I2=71%, MD 2.2, 95% Cl -0.84 to 5.23, P＞0.05). (Fig.8, Fig.9)

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WOMAC function, pain and stiffness

There were seven trials8,10,14,16,21-23 reported the data of WOMAC function, seven

trials8,10,14,16,21-23 reported the data of WOMAC pain and five trials10,14,16,21,23 reported

the data of WOMAC stiffness. The average WOMAC function scores in the

prehabilitation group did not improved extent than those in the control group (I2=0,
 MD -1.1, 95% Cl -3.92 to 1.72, P＞0.05). (Fig.10) There was no statistical difference in

the improvement of WOMAC stiffness score (I2=59%, MD -0.26, 95% Cl -0.65 to 0.13,

P＞0.05) and in the relief of pain (I2=57%, MD -0.23, 95% Cl -0.64 to 0.18, P＞0.05 )

among the two groups. (Fig11, Fig.12)

Discussion

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Most of patients are suffering quadriceps weakness before TKA and it may be worsen

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after TKA. Quadriceps strength has been shown to be inversely related with knee
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pain and function levels among patients with TKA24. Although postoperative

rehabilitation is an effective method to restore quadriceps strength and to reduce

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the length of hospital stay, it is still unclear whether the prehabilitation program is
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exhibit a similar effect. Rook22 reported that a 6-weeks preoperative exercise

improved the muscle strength and reduced the length of hospital stay. Huang12
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reported that a 4-weeks preoperative home rehabilitation education program prior

to TKA can reduce length of hospital stay. In contrast, Beaupre10 reported that the
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preoperative exercise had no significant effect on muscle strength of post-TKA

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patients. Our meta-analysis suggested that the prehabilitation program was

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necessary for it was effective in reducing the length of hospital stay. However, it was

no effect on quadriceps strength recovery in short terms following TKA. In the clinic,

6-minute walk test has been shown to be a reliable measure of recovery for patients

after TKA11. Interestingly, our meta-analysis result of the 6-minute walk test was

consistent with the quadriceps strength result, meanings that the prehabilitation

program had no effect on the functional recovery of patients following TKA. The
 reasons that the 6-minute walk test in the prehibilitation group was similar with the

control group, however, was not as yet clear. All the trials that reported the result of

6-minute walk in our meta-analysis found that there was no significant difference

between the two groups in short terms after TKA. This phenomenon may be

attributed to the similar quadriceps strength among the patients after TKA, then, it is

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necessary to further exploration of this phenomenon in the future studies.

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When the muscle strength impairments, the degree of knee extension and knee
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flexion also decrease. Previous studies25 reported that the knee extensor and flexor

muscle strength are highly relevant with functional performance following TKA. It has
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been shown that surgical procedures could impair the extensor mechanism and knee

flexors, hip abductors and hip extensors26. Therefore, it is important to restore

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muscle strength before and after TKA. However, opinions on the effect of
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prehabilitation exercise on knee extension and flexion were inconsistent.

Evgeniadis20 reported that the prehabilitation exercise program had no effect in

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increasing the active range of knee motion. However, Cavill19 reported that the
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prehabilitation exercise program was effective in improving knee flexion. Our

meta-analysis showed that there was no significant difference between the two
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groups in terms of extension and flexion. As our study found that there was no

significant difference in quadriceps strength among the two groups, it was logical to

find that the prehabilitation exercise program failed to improve knee extension and

flexion. However, there was significant difference between the two groups in terms

of knee ROM. This result may be attributable to the different training methods
 before TKA among the trials. Previous studies27 reported that sit-to-stand movement

could be as a performance-based measure for patients with TKA. In this

meta-analysis study, the sit-to-stand test was better in the prehabilitation group than

the control group. This result further supported the conclusion that the sit-to-stand

test was supporting the theory of prehabilitation9.

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Previous studies28,29 reported that patients with higher preoperative function are

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more likely to have better postoperative functional abilities. Therefore, it is necessary
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to improve preoperative functional abilities. Prehabilitation exercise has been proven

to exhibit a positive effect in improving the preoperative functional abilities of TKA

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patients7. Accordingly, it should also be sure to perform a positive effect in improving

the postoperative functional abilities. However, our meta-analysis failed to support

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this opinion as the WOMAC function score and WOMAC stiffness score had no
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significant difference among the two groups. Prehabilitation exercise has been shown

to affect recovery, as illustrated by reports of lower pain levels, when patients were
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given exercise training preoperatively9. The result of WOMAC pain score in our
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meta-analysis was inconsistent with previous studies6,30 as those studies reported

that prehabilitation before TKA could relieve the pain.

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A limitation of this meta-analysis was that the preoperative training protocol varies

among the studies. In our opinion, a proper training intensity of pre-TKA may have a

better effect on the quadriceps strength and knee range of motion. Besides, different

preoperative training protocol among trials may also resulted in the higher statistical

heterogeneity on some results of postoperative functions such as knee flexion. In

 addition, those outcomes that were not reported in English literature may change

the present results.

Conclusion

In conclusion, our meta-analysis found that the prehabilitation exercise was effective

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in reducing the length of hospital stay. Importantly, it was effective in improving knee

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ROM and sit-to-stand test. However, it did not alter quadriceps strength, 6-minute

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walk, WOMAC pain, WOMAC function, WOMAC stiffness, knee extension and flexion
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following TKA. Further studies with high quality are needed to confirm the

effectiveness of prehabilitation exercise program on patients undergoing TKA.

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Funding
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This paper was not funded.

Declaration of Interests
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The authors have no relevant affiliations or financial involvement with any

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organization or entity with a financial interest in or financial conflict with the subject
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matter or materials discussed in the manuscript. This includes employment,

consultancies, honoraria, stock ownership or options, expert testimony, grants or

patents received or pending, or royalties.

Acknowledgements
 Thanks are due to Bobin Mi for assistance with the analysis of data.

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Figure title and legend section

Fig.1 Flow chart showing study identification, inclusion and exclusion.

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Fig.2 Risk of bias summary.

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 Fig.3 Forest plot of length of hospital stay when compared prehabilitation exercise

group with control group.

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Fig.4 Forest plot of quadriceps strength when compared prehabilitation exercise

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group with control group.
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Fig.5 Forest plot of sit-to-stand when compared prehabilitation exercise group with
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control group.
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Fig.6 Forest plot of 6-minute walk when compared prehabilitation exercise group
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with control group.

Fig.7 Forest plot of knee ROM when compared prehabilitation exercise group with
 control group.

Fig.8 Forest plot of knee extension when compared prehabilitation exercise group

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with control group.

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Fig.9 Forest plot of knee flexion when compared prehabilitation exercise group with
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control group.
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Fig.10 Forest plot of WOMAC function when compared prehabilitation exercise group

with control group.

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Fig.11 Forest plot of WOMAC pain when compared prehabilitation exercise group
 with control group.

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Fig.12 Forest plot of WOMAC stiffness when compared prehabilitation exercise group

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with control group.
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 Table 1 The characteristics of included studies.

Patients(n) Age(Y) Gender

Qualit
Prehabilita Study
Study Year Country control y
Prehabil Prehabilit
control control tion design
itation ation scores
M F M F

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Beaupre 2004 Canada 65 66 67±7 67±6 26 39 33 33 RCT 5

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Cavil 2015 Australia 21 20 66.0±8.4 68.3±9.1 10 11 9 11 RCT 7

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Evgeniadis 2008 Greece 18 20 67.1±4.4 69.4±1.9 3 15 6 14 RCT 5

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Gstoettner 2010 Austria 18 20 72.8±15.7 66.9±12.6 2 16 6 14 RCT 5

Huang 2012 China 126 117

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69.8±7.2 70.5±7.4 38 88 31 86 RCT 3

Jakobsen 2014 Danmark 35 37 66±29.1 63±18 14 21 16 21 RCT 7

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Matassi 2012 Italy 61 61 66±7.2 67±7.7 28 33 35 26 RCT 4

McKay 2012 England 10 12 63.5±4.93 60.58±8.05 5 5 5 7 RCT 5

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Mitchell 2004 England 57 57 70.0±7.2 70.6±8.2 21 36 27 30 RCT 7

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Rooks 2006 England 22 23 65±8 69±8 11 11 10 13 RCT 4

Shurky 2016 Malaysia 24 26 62.4 64.3 2 22 5 21 RCT 5

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Skoffer 2016 Danmark 30 29 70.7±7.3 70.1±6.4 11 19 12 17 RCT 7

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Topp 2009 American 26 28 64.1±7.05 63.5±6.68 7 19 10 18 RCT 3

Tungtrongjit 2012 Thailand 30 30 63±7.6 65.9±7.2 4 26 6 24 RCT 7

Walls 2010 Ireland 9 5 64.4 ± 8.0 63.2 ± 11.4 3 6 1 4 RCT 5

Williamson 2007 England 60 61 70±8.79 69.6±10 29 31 28 33 RCT 7

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