• 
• 

Three Part Question

IN [Patients after a total hip joint replacement] IS [post-operative out-patient physiotherapy superior to home-based physiotherapy] AT [improving pain and functional outcomes].

Clinical Scenario

Current practice for patients after routine primary total hip replacement is to have unsupervised physiotherapy in the home-based setting followed by one hospital-based out-patient appointment check at 6 weeks post-op. A colleague feels that physiotherapy out-patient services should manage all post-op THR more frequently. You are concerned about the pressure on your out-patient service, particularly in view of the current COVID-19 pandemic limiting face-to face appointments. You want to establish what is the current evidence for physiotherapy in the home-based compared to the hospital-based settings.

Search Strategy

Search Terms:
‘hip arthroplasty’ OR ‘total hip replacement’
AND ‘physiotherapy’ OR ‘physical therapy’ OR ‘exercise therapy’ OR ‘physio$’ OR ‘rehabilitation’ OR ‘community rehabilitation’ OR ‘domiciliary rehabilitation’
AND ‘pain’ OR ‘functional outcomes’ OR ‘quality of life’

Search Strategy 2 2021-2022

‘hip arthroplasty’ OR ‘total hip replacement’
AND ‘physiotherapy’ OR ‘exercise therapy’ OR ‘physio$’ OR ‘rehabilitation’ OR ‘community rehabilitation’ OR ‘domiciliary rehabilitation’ OR ‘home therapy’

AND ‘pain’ OR ‘functional outcomes’ OR ‘quality of life’

NOT ‘knee arthroplasty’
This up-dated search was limited to 2021-2022 and English language. 67 studies were identified. An additional search criteria included NOT knee arthroplasty which reduced the total number to 47 studies. Of these 47 studies, only one was relevant, a randomised controlled trial, to the 3 part question.

Search Outcome

70 papers were retrieved. 6 were relevant to the 3-part question. These included 2 systematic reviews (2013 and 2019) and 4 randomised controlled trials (RCT). Two of the RCTs were discussed in the 2019 systematic review with meta-analysis and were therefore not included in the table. The RCT by Coulter was published in 2017 but was not included in the 2019 systematic review by Hansen. Overall 5 relevant papers were of sufficient quality to be included

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Coulter et al 2013 Australia	Adult patients after primary elective Total Hip Replacement (THR) 5 studies 234 participants	Systematic review Evidence level 1	1. hip strength 2. gait speed 3. functional measures (eg TUG) 4. Quality of life measures	Post op THR exercises are effective whether delivered in a supervised out-patient setting or unsupervised at home in improving strength and gait speed. The Timed Up and Go (TUG) test however was faster in the supervised group.	Unable to perform meta-analysis due to low number of studies (5). No definitive answer for QOL and functional outcome measures
Coulter et al 2017 Australia	Adult patients N=98 after unilateral primary elective THR Group 1. Supervised physiotherapy (circuit class) Group 2. Unsupervised (home-based) exercise program, in early post discharge phase.	Single-blinded RCT Evidence level 1	1.WOMAC 2. SF-36 3. TUG	No statistical difference between groups at 6 months point for 1.WOMAC 2. SF-36 3. TUG	Researchers were blind to group allocation, but patients were unable to be blinded due to the nature of the treatment groups. Lacked a true control group – improvements in both groups may be attributed to the natural recovery process rather than due to rehabilitation. Did not formally measure compliance in unsupervised group.
Hansen et al 2019 Denmark	Adult patients after primary THR Effectiveness of supervised exercises to unsupervised home-based exercises in early post-op period. 7 studies N=389	Systematic review with meta-analysis of RCTs Evidence level 1	Hip-related pain, health-related Quality of Life (QOL), performance-based function and long-term follow-up. All studies compared supervised to unsupervised exercises in patients with THR. The number of supervised sessions ranged from 12-30 treatments. Most patients in the unsupervised group received between 0-2 sessions.	528 studies screened and 7 included for qualitative and quantitative synthesis. Meta-analysis: Forrest plots – non-significant effect in favour of supervised groups in all outcomes. (Corresponds to findings of Coulter et al 2013).	Search limited from Nov 2013 – 2019 (replicating an earlier systematic review) Studies did not universally report on how patients complied with exercises in the non-supervised group. Study did not include Coulter 2017 RCT
Nelson et al 2020 Australia	Adults after primary THR N=70 Group1. Face-to-face out-patient setting n=35 Group2. Unsupervised telerehabilitation in patients’ homes n=35	Randomised controlled non-inferiority trial. Evidence level 1	1.QOL subscale from the HOOS (Hip Osteoarthritis Outcome score) 2.Objective measures of strength and balance, patient satisfaction scores, TUG (functional mobility)	1.No Difference found in strength balance and QOL measures at 6 weeks. 2.Both groups were equally weak in hip muscles at 6 weeks (due to surgical approach). High satisfaction scores in both groups Telerehabilitation not inferior to in-person treatment.	Single blinded trial (physiotherapist taking the measurement). Patients aware of group allocation. Control group had multiple therapists possibly affecting satisfaction with service.
Rao et al, 2021, USA	Adults after primary unilateral THR for osteoarthritis N=147 Both groups received pre-operative education and post-operative in-patient physiotherapy. Both groups completed a home exercise regime for the initial 2 week post-operative period, via paper hand-out. At 2 weeks post-op they were randomised into 2 groups: Group 1: (formal out-patient physiotherapy – face-to face appointments, once a week for 4 weeks ) n=72 Group 2: (unsupervised home based exercises – progression to more advanced exercises via handout) n=75	Prospective parallel RCT	Hip Disability and Osteoarthritis Outcome Score (HOOS) which includes subsections on pain, ADLs and function, and hip related Quality of Life Short Form-12 Health Survey (SF12v2) – a self-reported 12 question assessment on general health and well-being	N= 136 for final data analysis. There were 11 drop-outs. No significant difference in either outcome score for both groups. Both groups demonstrated improvements in the HOOS and SF12v2	Results less generalisable due to limits on age<76, low mean age (55.2) and BMI<40 Amount of formal physiotherapy was limited to once per week for 4 weeks – may not be enough time to demonstrate further improvements.

Comment(s)

A key systematic review (Hansen et al 2019) has concluded that in the early post-operative period, fewer face to face appointments followed by unsupervised home-based exercise regimes are equally as effective as more frequent supervised out-patient based regimes in improving pain and quality of life in patients who have had a total hip replacement. These findings support the findings of a previous systematic review and randomised controlled trials (Coulter et al 2013 and 2017, Nelson 2020). All the studies in the RCTs involved a primary THR.

Clinical Bottom Line

In summary, 2 sessions of supervised physiotherapy and subsequent unsupervised home-based exercises are comparable to 12-30 sessions of supervised hospital-based physiotherapy in achieving positive outcomes in patients after primary THR.

References

1. Coulter, C.L., Scarvell, J.M., Neeman, T.M. et al. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review. J Physiother. 2013 Dec;59(4):219-26.
2. Coulter, C., Perriman, D.M., Neeman, T.M et al. Supervised or unsupervised rehabilitation after total hip replacement provides similar improvements for patients: a randomized controlled trial. Arch Phys Med Rehabil. 2017 Nov;98(11):2253-2264.
3. Hansen, S., Aaboe, J., Mechlenburg, I.et al. Effects of supervised exercise compared to non-supervised exercise early after total hip replacement on patient-reported function, pain, health-related quality of life and performance-based function.. Clin Rehabil. 2019 Jan;33(1):13-23.
4. Nelson, M., Bourke, M., Crossley, K et al. Telerehabilitation is non-inferior to usual care following total hip replacement—a randomized controlled non-inferiority trial. Physiotherapy. 2020 Jun;107:19-27.
5. Rao, B.M., Cieslewicz, T.J., Sochacki, K.R.,et al Worse Preoperative Pain and Higher Activity Levels Predict Patient Choice of Formal Physical Therapy After Primary Anterior Total Hip Arthroplasty. The Journal of Arthroplasty, 2021;36(8), pp.2823-2828.