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Cochrane Database of Systematic Reviews

Post-acute physiotherapy for primary total hip arthroplasty


(Protocol)

Westby MD, Kennedy D, Carr S, Brander V, Bell M, Backman C

Westby MD, Kennedy D, Carr S, Brander V, Bell M, Backman C.


Post-acute physiotherapy for primary total hip arthroplasty.
Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005957.
DOI: 10.1002/14651858.CD005957.

www.cochranelibrary.com

Post-acute physiotherapy for primary total hip arthroplasty (Protocol)


Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Post-acute physiotherapy for primary total hip arthroplasty (Protocol) i


Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Protocol]

Post-acute physiotherapy for primary total hip arthroplasty

Marie D. Westby1 , Deborah Kennedy2 , Susan Carr1 , Victoria Brander3 , Mary Bell4, Catherine Backman5

1
Mary Pack Arthritis Program, Vancouver, Canada. 2 Department of Rehabilitation, Holland Orthopaedic and Arthritic Centre,
Toronto, Canada. 3 Northwestern Arthritis Institute, Chicago, IL, USA. 4 Department of Rheumatology, Sunnybrook Health Science
Center, North York, Canada. 5 Department of Occupational Science and Occupational Therapy, University of British Columbia,
Vancouver, Canada

Contact address: Marie D. Westby, Mary Pack Arthritis Program, 895 West 10th Ave, Vancouver, BC, V5Z 1L7, Canada.
marie.westby@vch.ca.

Editorial group: Cochrane Musculoskeletal Group.


Publication status and date: Edited (no change to conclusions), published in Issue 1, 2010.

Citation: Westby MD, Kennedy D, Carr S, Brander V, Bell M, Backman C. Post-acute physiotherapy for primary total hip arthroplasty.
Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005957. DOI: 10.1002/14651858.CD005957.

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

This is the protocol for a review and there is no abstract. The objectives are as follows:

The aim of this review is to determine the efficacy and effectiveness of post-acute physiotherapy (PT) on patients who have undergone
a primary THA for OA on patient-centred outcomes of pain, physical function and HRQOL. Various forms of PT and clinical settings
including inpatient rehabilitation, outpatient and home care programs will be compared to routine care, non-supervised or alternative
PT approaches. Post-acute PT will have been initiated within six-months post-surgery and completed within twelve-months post-
surgery.

Specific objectives are:

• To examine the short-term and long-term effects of post-acute physiotherapy on patient centred outcomes of pain, physical
function and HRQOL

• To compare measures of effectiveness across different clinical settings, patient characteristics and treatment approaches

• To report on the findings as they relate to implications to clinical practice

• To identify gaps in the published literature related to post-acute physiotherapy in the THA population

2005). This number is almost tenfold in the United States (AAOS


BACKGROUND
2005). The number of THA procedures in Canada grew by 33%
Total hip arthroplasty (THA) surgeries, which are also termed to- in the preceding nine-year period and by 11% in the preceding
tal hip replacements (THR), are common surgical procedures in one-year period (CJRR 2005). Similar one year growth rates are
North America and worldwide. Approximately 22,000 primary reported in other countries (March 2004). This number is pro-
THA surgeries were performed in Canada in 2002/03 (CJRR jected to grow with the aging population, increased prevalence of
Post-acute physiotherapy for primary total hip arthroplasty (Protocol) 1
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
osteoarthritis in the elderly and advances in prosthetic design and cent years has shifted immediate rehabilitation services to outpa-
materials (Badley 1995; Jones 2005). Other factors contributing tient or rehabilitation settings or, in some cases, it is omitted al-
to the increase in the number of these procedures are higher com- together. Such rehabilitation practice variation exists worldwide
munity expectations for improved quality of life and improved (Roos 2003).
surgical and anaesthetic techniques that have made these surg-
A number of authors have reported that persistent pain, prolonged
eries appropriate and safer for both older and younger patients
physical impairments (range of motion, muscle strength and re-
(March 2004; Swedish 2003). Current data from international
cruitment, proprioception) and some functional limitations (pos-
joint arthroplasty registries indicate that osteoarthritis is the pri-
tural stability, walking speed, stair ascent/descent) persist more
mary reason for surgery and contributes to between 75% (Furnes
than one year following THA and TKA (Brander 2001; Shih 1994;
2004; Swedish 2003) and 95% (NJR 2005) of all THA procedures.
Trudelle-Jacks. 2002; Walsh 1998). Despite many of the subjects
Joint replacement surgery has enormous socioeconomic impacts
in these studies receiving some form of physical therapy during the
on healthcare costs and has been shown to decrease pain, improve
acute and/or subacute phases, authors suggest that current exercise
mobility and function, and improve quality of life (Brander 2001;
programs performed during the early phase of rehabilitation are
Ethgen 2004; Salmon 2001). However, due to the rapid growth in
insufficient to restore muscle strength, postural stability and other
both primary and revision procedures, joint replacement surgery
functional activities. As well, reduced physical capacity coupled
places a significant burden on healthcare budgets (March 2004).
with further reduction of reserve capacity seen with normal aging
The American Academy of Orthopaedic Surgeons (AAOS) has
may lead to declining independence in daily living for older adults
published data from 2002 on their web site that indicates total
(Walsh 1998). Patients who have undergone THA surgery should
hospitalization costs for primary THA procedures in the US was
probably continue their therapeutic exercise program for at least a
$5.91 billion (US) (AAOS 2005).
year and be given a more advanced exercise program later in their
In the past decade, hospitalization following THA has decreased recovery. (Trudelle-Jacks. 2002) However, we do not know exactly
by 30% in Canada. Data from 2002/03 show that the average what kind of therapeutic exercises performed over what period of
acute hospital length of stay (LOS) to be 9.6 days for all THA time are effective or necessary to enhance short and long-term sur-
procedures, including revisions (CJRR 2005). More recent data gical outcomes and optimize patient function, activity and quality
suggests even shorter LOS when only primary procedures are con- of life.
sidered (AAOS 2005; March 2004). Earlier discharge to home or
community services decreases the time available for physical recu-
peration, inpatient rehabilitation and patient and family education Therapeutic exercises and protocols within a rehabilitation pro-
and counseling. A reduced LOS places additional responsibility on gram are largely based on clinical experience, surgeon preferences
the patients, their family and their community-based health care and anecdotal reports. One author notes that essentially no guid-
providers to monitor and identify post-operative complications ance exists to assist the clinician recommending activities follow-
such as infection, deep vein thromboses and anaemia. As well, the ing discharge from the acute care setting (Givens-Heiss 1992). In
short acute care stay puts more emphasis on preadmission edu- our own experience, there is confusion about “best practice” and
cation and the role and timing of physical therapy interventions pressure to reduce length of stay and discharge patients quickly,
following discharge. In an editorial examining LOS after THA without adequate evidence regarding the effect of these decisions.
and total knee arthroplasty (TKA), Johanson comments that “it While we have observed some patients returning to hospital for
remains unclear just how far this process [of reducing LOS] can be services, and others with persistent problems, there has been no
taken without either compromising quality of care or simply shift- systematic follow up regarding their long term functional ability
ing costs to a less regulated outpatient environment” (Johanson and surgical outcome.
1997). In the final report of the National Institutes of Health (NIH)
1994 Consensus Development Conference (CDC) on THA the
To date, no evidence-based practice guidelines have been devel-
authors concluded: “The benefits of a long-term therapeutic exer-
oped to guide best practice for post-acute rehabilitation following
cise program for patients who have undergone total hip replace-
THA and TKA. Yet the majority of patients in Canada and else-
ment (THR) have not been clearly demonstrated to improve mo-
where receive some form of post-operative physical therapy (PT)
bility or hip stability. There appears to be insufficient appreciation
and other rehabilitative services through inpatient rehabilitation,
for the role of exercise in THR rehabilitation; however, there is
skilled nursing facilities, outpatient or home care services. Dis-
evidence that hip weakness persists up to 2 years after surgery in
charge data for Ontario, Canada hospitals in the one-year period
the presence of a normal gait. Multiple studies have demonstrated
2001-2002 revealed that of the 6,323 primary THAs performed,
that weakness in the lower extremities is a major risk factor for
approximately 70% received post-acute rehabilitation from an in-
falls in the geriatric age-group” (NIH 1994).
patient rehabilitation hospital and/or through home care services
(Jaglal 2004). Decreased length of acute care hospital stays in re- Despite a decade having passed since this consensus conference,

Post-acute physiotherapy for primary total hip arthroplasty (Protocol) 2


Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
few empirical studies have been published addressing these con- clinical settings including inpatient rehabilitation, outpatient and
cerns. A more recent 2003 NIH consensus meeting and final report home care programs will be compared to routine care, non-super-
addressing total knee replacement (TKR) concluded that similarly vised or alternative PT approaches. Post-acute PT will have been
to THR, “there is a notable lack of consensus regarding which initiated within six-months post-surgery and completed within
medical and rehabilitative peri-operative practices should be em- twelve-months post-surgery.
ployed, mostly because of the lack of well-designed studies testing
Specific objectives are:
the efficacy and effectiveness of such practices.” (NIH 2003) It
was further stated that “the use of rehabilitation services is perhaps
• To examine the short-term and long-term effects of post-
the most understudied aspect of the peri-operative management
acute physiotherapy on patient centred outcomes of pain,
of TKR patients” and “no evidence-based guidelines exist for pro-
physical function and HRQOL
moting or limiting post-TKR physical activity” (NIH 2003). As
suggested by both NIH reports, a study of the contribution of pre- • To compare measures of effectiveness across different
, in- and post-hospital education and rehabilitation programs to clinical settings, patient characteristics and treatment approaches
the eventual outcome of the surgical procedure is needed. This in-
• To report on the findings as they relate to implications to
depth study is needed to determine optimum regimen, treatment
clinical practice
duration, and expected outcomes as clinical data suggests that po-
tential capabilities of the patients are not being fully developed • To identify gaps in the published literature related to post-
(NIH 1994). As with the hip, the term total knee “arthroplasty” acute physiotherapy in the THA population
or TKA will be used to refer to “replacement” or TKR throughout
the remainder of the review.
As part of the larger project to develop evidence-based clinical METHODS
practice guidelines for peri-operative rehabilitation for patients
undergoing THA and TKA, systematic reviews are being under-
taken to examine the current literature relating to the evaluation Criteria for considering studies for this review
of various rehabilitation approaches and interventions in this pa-
tient population. Another Cochrane review currently underway is
comparing the effect of multidisciplinary rehabilitation interven- Types of studies
tions to single discipline care following primary and revision THA
The following study designs will be included in the review:
and TKA (Khan 2004). This review, however, is focusing on the
• Randomized controlled trials (RCTs)
acute care phase of rehabilitation and is including use of clinical
• Controlled clinical trials (includes quasi-randomized and
pathways, formal patient education programs, post-operative pain
controlled before-after designs)
management and dietary interventions in its range of outcomes.
Our first of several reviews will address the question of whether Designs not included in this review are cohort, case-control, single
post-acute physiotherapy following primary THA is effective on case studies, single subject, case series and pre/post studies with
a number of patient centred outcomes including pain, physical no control group.
functioning and health-related quality of life (HRQOL). Criteria
for selecting a clinical topic or issue for guideline development
Types of participants
include prevalence of the clinical condition, variations in health
practices, lack of high quality evidence to support practice, poten- Adults aged 19 years or older who have undergone an elective,
tial to change health outcomes, costs, and feasibility (CPA 1996), primary THA for primary (idiopathic) or secondary OA due to
all of which are met by our topic of THA and TKA rehabilitation. trauma, developmental or congenital problems. Surgical proce-
A detailed, systematic approach is needed to develop a document dures include all forms of fixation (cemented, hybrid or cement-
that will guide both health professionals and patients in determin- less with/without porous coating), surgical approaches (anterolat-
ing optimal rehabilitation strategies following THA. eral, lateral, posterolateral) and types of prosthetic bearing surfaces
(metal, polyethylene, ceramic). Participants will be excluded if they
have: undergone revision THA; hemi-arthroplasty or resurfac-
ing procedure; an inflammatory diagnosis (i.e. rheumatoid arthri-
OBJECTIVES
tis, ankylosing spondylitis); acute fracture; had significant pre or
The aim of this review is to determine the efficacy and effective- peri-operative complications (intraoperative fracture, nerve palsy,
ness of post-acute physiotherapy (PT) on patients who have un- wound infection, severe anaemia, deep vein thrombosis (DVT),
dergone a primary THA for OA on patient-centred outcomes of pulmonary embolis (PE), pneumonia) or an extended acute hospi-
pain, physical function and HRQOL. Various forms of PT and tal stay beyond the standard LOS for that hospital facility. Studies

Post-acute physiotherapy for primary total hip arthroplasty (Protocol) 3


Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
with mixed pre-surgical diagnoses will be included if 90% or more • Process measures (including length of rehabilitation stay/
of the participants have an OA diagnosis. program, number of treatment sessions (volume), frequency of
treatment (intensity), adherence to treatment and timing of
treatment (delayed or immediate))
Types of interventions
Post-acute physiotherapy includes physiotherapy provided in any
setting (in-patient rehabilitation, outpatient hospital/clinic, pri- Search methods for identification of studies
vate practice clinic, home/community-based care) that immedi-
Electronic database search
ately follows (within 1 week) discharge from the acute care ward
or hospital setting or is initiated within 12 months of the date of
The following electronic data bases will be used to identify relevant
surgery. Physiotherapy includes 1:1 and group interventions con-
studies published between January 1990 and December 31, 2005:
ducted by the PT and/or a trained PT assistant under the direct su-
• MEDLINE
pervision of the PT. Interventions may include alone or in combi-
• CINAHL
nation: therapeutic exercise; hydrotherapy; use of thermal or elec-
• EMBASE
trical modalities (i.e. cyrotherapy, heat, transcutaneous electrical
• Cochrane Central Register of Controlled Trials
nerve stimulation (TENS) and functional electrical muscle stim-
(CENTRAL)
ulation (FEMS)); postural, proprioceptive and balance retraining;
• Cochrane Musculoskeletal Group Trials Register
gait retraining; functional exercises; cardiovascular fitness; manual
• PEDro (Physiotherapy Evidence Database)
therapy techniques (i.e. soft tissue massage, passive range of mo-
• Web of Science
tion (ROM), hold-relax); and patient education.
Supervised physiotherapy will be compared to control groups who No language restrictions will be applied. The following search
received routine care (standard or traditional physiotherapy for a strategy will be used to search MEDLINE using a combination
given institution or surgeon), “attention only” (no active interven- of MeSH and key words. The quality filter recommended by the
tion), unsupervised home exercises or other operationalized com- Cochrane Musculoskeletal Review Group will be applied.
parators (which may include comparing one physiotherapy pro- See Appendix 1 for MEDLINE (OVID) Search Strategy using the
gram or therapeutic setting to another). EBM Filter for Therapy (Phase 3 Study).
Other electronic search strategies will be included in “Appendices”
in the full review.
Types of outcome measures Other sources
The primary outcomes of interest are:
• Post-operative pain We will scan reference lists of articles, review papers and textbooks
• Physical function (as measured by validated functional for additional papers. Known experts in the field and authors of
assessment self report tools, physician/health professional scored existing, high quality studies will be contacted for additional ref-
tools or observed performance measures erences. Their CVs will be searched for on the Web to ensure
• Health-related quality of life (as measured by a validated lists of publications are complete. The Web of Science will also be
generic, condition-specific, individualized or preference-based searched for cited publications.
instrument) Grey literature search

Secondary outcomes will examine: The grey literature search will be conducted using the following
• Body structure and function (hip ROM, lower extremity strategies to identify published and unpublished papers, reports
muscle strength and endurance, soft tissue flexibility, balance, and other documents:
proprioception, cardiopulmonary function/aerobic fitness, Conference proceedings and papers from congresses and sympo-
Trendelenburg sign, leg length discrepancy) siums will be searched through the databases PapersFirst and Pro-
• Activity (activities of daily living) ceedingsFirst.
• Participation (return to work, return to leisure activities, Hand searching conference proceedings (January 2000 - Septem-
driving, sexual activity) ber 2005)
• Patient satisfaction • American Academy of Orthopedic Surgeons Annual
• Surgical outcomes and complication rates (dislocation, Meeting
hospital readmission, radiographic prosthetic loosening, revision/ • American Academy of Physical Medicine and
survivorship of prosthesis) Rehabilitation Annual Assembly
• Adverse effects due to rehabilitation (such as increased pain, • American College of Rheumatology Annual Scientific
dislocation, falls) Meeting

Post-acute physiotherapy for primary total hip arthroplasty (Protocol) 4


Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
• American Physical Therapy Association • National Joint Registry (Britain) www.njrcentre.org.uk
• Association of Rheumatology Health Professionals Annual • New Zealand National Joint Register www.cdhb.govt.nz/
Scientific Meeting NJR
• British Orthopaedic Association (published in J Bone Joint • Norwegian Arthroplasty Register www.haukeland.no/nrl
Surg-Br) • Swedish National Hip Arthroplasty Register
• Canadian Orthopaedic Association (published in J Bone www.jru.orthop.gu.se
Joint Surg-Br)
• Canadian Physiotherapy Association Annual Congress
• Hip Society (published in Clin Ortho Rel Res)
• National Association of Orthopaedic Nurses (published in Data collection and analysis
Orthopaedic Nursing)
Selection of studies
Hand searching key journals (January 2000 - September 2005)
• Archives of Physical Medicine and Rehabilitation A team of four primary reviewers (MW, SC, DK and VB) and
• Arthritis Care and Research two tie breakers with methodological expertise (CB and MB) has
• Arthritis and Rheumatism been assembled. The lead review (MW) and one other primary re-
• Acta Orthopaedic Scandinavica viewer will independently screen all identified papers by scanning
• Clinical Orthopaedics and Related Research abstracts and/or portions of the text to determine if they meet the
• Clinical Orthopaedics inclusion criteria.
• Journal of Arthroplasty Data extraction
• Journal of Bone and Joint Surgery -American
• Journal of Bone and Joint Surgery-British Those papers meeting the inclusion criteria will be reviewed in
• Orthopaedic Nursing full by the same two independent reviewers and data will be ex-
• Orthopaedics tracted using a standardized paper form. Separate data extraction
• Physical Therapy forms will be developed for RCTs and observational studies. Any
• Physiotherapy disagreement will be resolved through consensus to discuss and
• Physiotherapy Canada resolve disagreements between the two reviewers. If disagreement
persists, one of the independent tie breakers (CB or MB) will be
Searching professional organizations’ web sites (September 2005) consulted. Study authors will be contacted if additional informa-
• American Academy of Orthopaedic Surgeons www.aaos.org tion is necessary.
• American Academy of Physical Medicine and Assessment of methodological quality
Rehabilitation www.aapmr.org
• American College of Rheumatology www.rheumatology.org Methodological quality of the studies will be assessed using the
• American Physical Therapy Association www.apta.org scale by van Tulder et al. (van Tulder 2003) for RCTs and CCTs.
• Association of Rheumatology Health Professionals This 11-item quality assessment scale developed for use by the
www.rheumatology.org/arhp Cochrane Back Review Group was chosen for its relevance to the
• British Orthopaedic Association www.boa.ac.uk topic and likely interventions. Studies scoring six or more out of
• Canadian Orthopaedic Association www.coa-aco.org the possible 11 points will be considered of higher quality for a
• Canadian Orthopaedic Nurses Association www.cona- sensitivity analysis if meta-analysis is appropriate.
nurse.org Quality assessment checklist (van Tulder 2003)
• Canadian Physiotherapy Association www.physiotherapy.ca 1. Was the method of randomization adequate?
• Hip Society www.hipsoc.org 2. Was treatment allocation concealed?
• International Society of Orthopaedic Surgery 3. Were groups similar at baseline regarding most important prog-
and Traumatology www.sicot.org nostic factors?
• National Association of Orthopaedic Nurses 4. Was the patient blinded to the intervention?
www.orthonurse.org 5. Was the therapist/care provider blinded to the intervention?
6. Was the outcome assessor blinded to the intervention?
Searching national joint arthroplasty registries 7. Were co-interventions avoided or similar?
• Australian National Joint Replacement Registry 8. Was compliance acceptable in all groups?
www.dmac.adelaide.edu.au/aoanjrr 9. Was the drop-out rate described and acceptable(20% or less for
• Canadian Joint Replacement Registry www.cjrr.org post-test, 30% or less for long term follow up)
• Finnish Arthroplasty Register www.namfi/english/ 10. Was the timing of the outcome assessment similar in both
publications/medicaldevices.html groups?

Post-acute physiotherapy for primary total hip arthroplasty (Protocol) 5


Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
11. Was data for at least one key outcome analyzed by intention The bronze ranking is given to evidence if at least one high quality
to treat? case series without controls (including simple before/after studies
Initial interobserver reliability of both the screening (include or in which patients act as their own control) or if the conclusion is
exclude) and quality assessment will be determined by calculating derived from expert opinion based on clinical experience without
Kappa scores on a limited sample of papers prior to the actual reference to any of the foregoing (for example, argument from
review process. These related studies will be drawn from a pool of physiology, bench research or first principles).
articles that do not meet the inclusion criteria due to publication The data will be examined for clinical and methodological hetero-
date or difference in intervention or patient population (van Tulder geneity taking into account the participants, interventions, con-
2003). Poor agreement during this pilot test phase will result in trols, outcomes, measurement tools and methodological quality of
revisions to the screening and data extraction forms and further the original studies (van Tulder 2003). Where appropriate to pool
discussion and clarification will take place among reviewers prior results, we will use weighted mean differences (WMD) for con-
to the actual review. tinuous data using the same measurement scales and standardized
Data analysis and synthesis mean differences (SMD) for continuous outcomes using different
The continuous data from individual trials will be recorded as scales. Both sets of summary statistics will be pooled by using the
means and standard deviations and dichotomous outcomes will be inverse variance method. Data derived from short ordinal scales
presented as contingency tables. We will prepare evidence tables will be collapsed and treated as dichotomous data in order to cal-
and perform a qualitative analysis using Sackett’s updated Levels culate risk ratios (RR). Dichotomous variables will be pooled by
of Evidence (Phillips 2001). The grading system recommended by the Mantel-Haenszel method using RR.
the Cochrane Musculoskeletal Group and developed by Tugwell In each case, we will test for statistical heterogeneity to determine
et al. (Tugwell 2004) will be applied whereby the overall evidence if it is appropriate to combine the studies for meta-analysis. Het-
is ranked from high to low quality using: erogeneity will be examined graphically through the use of the for-
Platinum: est plot and statistically through calculating the I2 statistic which
A published systematic review that has at least two individual describes the percentage of the variability in effect estimates that is
controlled trials each satisfying the following : due to heterogeneity rather than sampling error (chance). A value
·Sample sizes of at least 50 per group - if these do not find a greater than 50% may be considered substantial heterogeneity. We
statistically significant difference, they are adequately powered for will proceed to calculate the random effects estimates for the cor-
a 20% relative difference in the relevant outcome. responding statistics using the DerSimonian and Laird method.
·Blinding of patients and assessors for outcomes. Although the pooled effect estimate from a fixed effect meta-anal-
·Handling of withdrawals >80% follow up (imputations based on ysis is considered as being the best estimate of the treatment effect,
methods such as Last Observation Carried Forward (LOCF) are this model ignores heterogeneity among trials and the fact that
acceptable). there may not be a single treatment effect but a distribution of
·Concealment of treatment allocation. treatment effects (Higgins 2005).
Gold: Forest plots will be created to display effect estimates with 95%
At least one randomised clinical trial meeting all of the following confidence intervals for individual trials and pooled results. Ad-
criteria for the major outcome(s) as reported: ditional analyses will include assessing for publication bias using
·Sample sizes of at least 50 per group - if these do not find a funnel plots, explaining heterogeneity through subgroup analyses
statistically significant difference, they are adequately powered for (age, pre-operative functional status, comorbidities, and rehabil-
a 20% relative difference in the relevant outcome. itation setting, dosage (intervention duration and intensity) and
·Blinding of patients and assessors for outcomes. timing (immediate (within 1 week of discharge from acute care
·Handling of withdrawals > 80% follow up (imputations based on setting), intermediate (1 week to 6 months) and delayed (greater
methods such as LOCF are acceptable). than 6 months post-op))and performing sensitivity analyses to ad-
·Concealment of treatment allocation. dress the effects of differences in study design (RCTs vs. CCTs),
Silver: methodological quality and missing data (intention-to-treat ver-
A randomised trial that does not meet the above criteria. Silver sus on-protocol results) on overall results. Using meta-regression
ranking would also include evidence from at least one study of methods, we will explore some of the heterogeneity in the data
non-randomised cohorts that did and did not receive the therapy, and use baseline scores and time (follow-up intervals) as some of
or evidence from at least one high quality case-control study. A the explanatory covariates.
randomised trial with a ’head-to-head’ comparison of agents would Clinical relevance tables:
be considered silver level ranking unless a reference were provided Clinical relevance tables will be compiled under additional tables
to a comparison of one of the agents to placebo showing at least a to improve the readability of the review. For dichotomous out-
20% relative difference. comes, the number needed to treat will be calculated from the
Bronze: control group event rate and the relative risk using the Visual Rx

Post-acute physiotherapy for primary total hip arthroplasty (Protocol) 6


Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
NNT calculator (Cates 2004). Continuous outcome tables will ACKNOWLEDGEMENTS
also be presented under additional tables. Absolute benefit will be
The authors would like to thank Michael Schulzer, MD, PhD,
calculated as the improvement in the intervention group minus
for assisting with the design of the data extraction and analysis
the improvement in the control group, in the original units. Rel-
sections, Mimi Doyle-Waters, MA, MLIS, for her valuable help
ative difference in the change from baseline will be calculated as
with the development of the search strategy and research assistants
the absolute benefit divided by the baseline mean of the control
Osita Hibbert and Michelle Raglin. In addition, we appreciate the
group.
help and guidance from Lara Maxwell of the Cochrane Muscu-
loskeletal Group.

REFERENCES

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www.nntonline.net, 2004. Jones 2005
Jones CA, Beaupre LA, Johnston DWC, Suarez-Almazor
CJRR 2005 ME. Total joint arthroplasties: Current concepts of patient
Canadian Institute for Health Information (CIHI). outcomes after surgery. Clinics in Geriatric Medicine 2005;
Canadian Joint Replacement Registry (CJRR) Total Hip 21:527–41.
and Total Knee Replacements in Canada 2005 Report.
Ottawa: CIHI. URL: www.cihi.ca/cjrr Accessed September Khan 2004
28, 2005.. Khan F, Disler P. Multidisciplinary rehabilitation
interventions for joint replacement at the knee and hip for
CPA 1996
arthropathies (protocol). Cochrane Database of Systematic
Canadian Physiotherapy Association. Clinical Practice
Reviews 2004, Issue 4.
Guidelines: A discussion paper for the Canadian
Physiotherapy Association. May 1996. March 2004
March LM, Bagga H. Epidemiology of osteoarthritis in
Ethgen 2004 Australia. Medical Journal of Australia 2004;180:S6–S10.
Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY.
Health-related quality of life in total hip and total knee NIH 1994
arthroplasty. A qualitative and systematic review of the National Institutes of Health. Total hip replacement, NIH
literature. Journal of Bone and Joint Surgery-Am 2004;86 Consensus Statement. URL: http://consensus.nih.gov/
(A5):963–74. 1994/1994HipReplacement098html.htm 1994.
Furnes 2004 NIH 2003
Furnes O, Havelin LI, Espehaug B. The Norwegian National Institutes of Health. Consensus statement on total
Arthroplasty Register. 2004 Annual Report. URL: http:// knee replacement. URL: http://consensus.nih.gov/cons/
www.haukeland.no/nrl/ Accessed September 27, 2005. 117/117cdc_intro.htm. 2003. Accessed March 17, 2004..
Post-acute physiotherapy for primary total hip arthroplasty (Protocol) 7
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
NJR 2005 September 26, 2005..
National Joint Registry for England and Wales 2nd Annual Trudelle-Jacks. 2002
Report. URL: www.njrcentre.org.uk/documents/reports/ Trudelle-Jackson E, Emerson R, Smith S. Outcomes of total
NJR2_fullreport.pdf September 2005. hip arthroplasty: A study of patients one year postsurgery.
Phillips 2001 Journal of Orthopaedic and Sports Physical Therapy 2002;32:
Phillips B, Ball C, Sackett D, Badenoch D, Straus S, Haynes 260–7.
B, Dawes M. Oxford Centre for Evidence-based Medicine Tugwell 2004
Levels of Evidence (May 2001). URL: www.cebm.net/ Tugwell P, Shea B, Boers M, Simons L, Strand V, Wells G.
levels_of_evidence.asp Accessed August 13, 2005.. Evidence-based Rheumatology. BMJ books, 2004.
Roos 2003 van Tulder 2003
Roos EM. Effectiveness and practice variation of van Tulder M, Furlan A, Bombardier C, Bouter L. Updated
rehabilitation after joint replacement. Current Opinion in method guidelines for systematic reviews in the Cochrane
Rheumatology 2003;15:160–2. Collaboration Back Review Group. Spine 2003;28(12):
Salmon 2001 1290–9.
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C. Recovery from hip and knee arthroplasty: Patients’ Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical
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Medicine and Rehabilitation 2001;82:360–6. subjects. Physical Therapy 1998;78:248–58.
Shih 1994 Wells
Shih CH, Du YK, Lin YH, Wu CC. Muscular recovery GA Wells, B Shea, D O’Connell, J Peterson, V Welch, M
around the hip joint after total hip arthroplasty. Clinical Losos, P Tugwell. The Newcastle-Ottawa Scale (NOS)
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Swedish National Hip Arthroplasty Register 2003 Annual epidemiology/oxford.htm. Accessed July 13, 2005.
Report. URL: http://www.jru.orthop.gu.se Accessed ∗
Indicates the major publication for the study

APPENDICES

Appendix 1. MEDLINE search strategy


1. arthroplasty, replacement, hip/
2. hip prosthesis/
3. joint prosthesis/
4. (hip adj5 (arthroplast$ or replac$ or prosthe$)).mp. [mp=title, original title, abstract, name of substance word, subject heading
word]
5. or/1-4
6. physical therapy techniques/ or cryotherapy/ or electric stimulation therapy/ or transcutaneous electric nerve stimulation/ or hy-
drotherapy/
7. exercise movement techniques/ or exercise/ or exercise therapy/ or walking/
8. rehabilitation/ or “activities of daily living”/ or early ambulation/
9. Postoperative Care/
10. Clinical Protocols/
11. Ambulatory Care/
12. Rehabilitation Centers/
13. Home Care Services/
14. (physiotherap$ or physio therap$ or pt).mp. [mp=title, original title, abstract, name of substance word, subject heading word]
15. therap$.mp. [mp=title, original title, abstract, name of substance word, subject heading word]
16. rehab$.mp. [mp=title, original title, abstract, name of substance word, subject heading word]
Post-acute physiotherapy for primary total hip arthroplasty (Protocol) 8
Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
17. or/6-16
18. Pain, Postoperatiave/pc(prev & control)
19. “Recovery of Function”/
20. “Quality of Life”/
21. Health Status/
22. “outcome and process assessment (health care)”/ or “outcome assessment (health care)”/ or treatment outcome/ or treatment failure/
or “process assessment (health care)”/
23. (outcome$ adj3 (assess$ or measur$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word]
24. pain$.mp. [mp=title, original title, abstract, name of substance word, subject heading word]
25. (function$ adj5 (mobili$ or outcome$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word]
26. (quality adj3 life).mp. [mp=title, original title, abstract, name of substance word, subject heading word]
27. (QOL or HRQOL).mp. [mp=title, original title, abstract, name of substance word, subject heading word]
28. ambulat$.mp. [mp=title, original title, abstract, name of substance word, subject heading word]
29. gait.mp. [mp=title, original title, abstract, name of substance word, subject heading word]
30. (walk adj5 (speed or distance$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word]
31. or/18-30
32. Randomized Controlled Trial.pt.
33. controlled clinical trial.pt.
34. randomized controlled trials.sh.
35. random allocation.sh.
36. double blind method.sh.
37. single blind method.sh.
38. or/32-37
39. (animals not human).sh.
40. 38 not 39
41. Clinical Trial.pt.
42. exp Clinical Trials/
43. (clin$ adj25 trial$).ti,ab.
44. ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or mask$)).ti,ab.
45. placebos.sh.
46. placebo$.ti,ab.
47. random$.ti,ab.
48. research design.sh.
49. or/41-48
50. 49 not 39
51. comparative study.sh.
52. exp evaluation studies/
53. follow up studies.sh.
54. prospective studies.sh.
55. (control$ or prospectiv$ or volunteer$).ti,ab.
56. or/51-55
57. 56 not 39
58. or/40,50,57
59. 5 and 17
60. 5 and 17 and 31
61. 5 and 17 and 31 and 58
62. limit 61 to yr=“1990 - 2005”

Post-acute physiotherapy for primary total hip arthroplasty (Protocol) 9


Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
WHAT’S NEW

Date Event Description

25 July 2008 Amended Converted to new review format.


CMSG ID: C145-P

CONTRIBUTIONS OF AUTHORS
Westby M - Project coordinator and main reviewer; conceived, designed and coordinated the review; developed the search strategy and
will oversee the undertaking of the searches, the screening and critical appraisal of papers; prepared the review protocol and will write
the review
Kennedy D - Co-reviewer; provided feedback on the screening and data extraction forms; will assist in screening and critically appraising
retrieved papers; will extract data from papers and help with the interpretation of data by providing a clinical perspective; will provide
feedback on the review
Carr S - Co-reviewer; provided feedback on the screening and data extraction forms; will assist in screening and critically appraising
retrieved papers; will extract data from papers and help with the interpretation of data by providing a clinical perspective; will provide
feedback on the review
Brander V - Co-reviewer; will provide feedback on screening and data abstraction forms and review protocol; will assist in screening
and critically appraising retrieved papers; will extract data from papers and help with the interpretation of data by providing a clinical
perspective; will provide feedback on the review
Backman C - Secondary (tie breaker) reviewer; assisted in the design of the review; provided feedback on the protocol; will assist
in critically appraising papers when consensus cannot be reached by primary reviewers; will help with the interpretation of data by
providing a methodological perspective; will assist in writing the review; secured funding for the review
Bell M - Secondary (tie breaker) reviewer; provided input and feedback on protocol; will assist in critically appraising papers when
consensus cannot be reached by primary reviewers; will help with the interpretation of data by providing a methodological perspective;
will provide general advice and feedback on the review

DECLARATIONS OF INTEREST
None. One secondary reviewer (CB) is a co-investigator on a current trial examining the effectiveness of out-patient physiotherapy
following THA compared to a minimally supervised home exercise program. The results of this trial will not be published during the
time frame of this systematic review.

SOURCES OF SUPPORT

Post-acute physiotherapy for primary total hip arthroplasty (Protocol) 10


Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Internal sources
• No sources of support supplied

External sources
• The John Insall Foundation for Orthopaedics, USA.
• Canadian Institutes of Health Research, Canada.

Post-acute physiotherapy for primary total hip arthroplasty (Protocol) 11


Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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