Running Head: Effects of Prehabilitation on Quality of Life
Prehabilitation and Quality of Life Three Months after Total Knee Arthroplasty: A
Bellarmine University Lansing School of Nursing
Exercise Science Department
Robert Topp, Marquette University
College of Nursing
Joseph A. Brosky
Bellarmine University, Physical Therapy
and A. Scott LaJoie
School of Public Health and Information Science
Department of Health Promotion and Behavioral Sciences
Address correspondence to
Kent Brown, Ph.D., M.S., CSCS
Bellarmine University, Exercise Science Department
1961 Bishops Lane, Room 107
Louisville, Ky. 40205 or email (email@example.com)
This study was supported by the Hygenic Research Fund at The University of Louisville
Knee osteoarthritis affects over 27 million Americans, lessening quality of life by
decreasing mobility, deconditioning, reducing functional ability, and increasing knee pain. The
present study assessed whether 11 patients (7 females, 4 males, age 60 ± 8.3) who engaged in
exercise prior to prehabilitation (preoperative exercise intervention) rated themselves as having a
higher quality of life 3 months after their surgery compared to a group of 7 patients (5 female, 2
males, age 67 ± 9.5) who did not engage in prehabilitation, but only standard preoperative care.
Standard preoperative care would mean the control group did not perform any special exercise
activities other than normal activities of daily living. The prehabilitation group exercised three
times a week, twice at home and once in the physical therapy lab for 8 weeks prior to the
operation. Patients in both groups rated eight health related quality of life domains three months
after surgery. Compared to population norm ratings for knee patients, the prehabilitation group
rated themselves higher on all eight domains: physical and social functioning, physical and
emotional role, general health, mental health, and lower on bodily pain than population norms.
However, due to the small groups and low statistical power, comparisons between
treatment and control groups showed a significant difference only on physical functioning, with
the treatment group rating themselves higher than the control. The pilot results suggest that the
prehabilitation treatment may significantly improve ratings across all eight domains, but that
larger samples are needed to justify that conclusion.
Knee osteoarthritis is typically characterized by joint pain and dysfunction resulting from
joint degeneration and loss of articular cartilage (Buckwalter & Martin, 2006). Osteoarthritis,
also known as degenerative joint disease, is one of the most common forms of arthritis among
U.S. adults and is a leading cause of disability (Osteoarthritis, 2000; Prevention, 2006,
Lawrence, et al., 2008; Foundation, 2009). This disease is one of most common chronic health
problems in the U.S. today, affecting over 27 million Americans, up from an estimated of 21
million in 1995 (Centers for Disease Control and Prevention, 2001; Lawrence, et al., 2008). With
59% of adults over age of 65 years affected by this disease, its occurrence is projected to increase
with the aging population of the USA (Centers for Disease Control and Prevention, 2002).
Osteoarthritis is a major cause of disability among older adults (Hughes, Seymour,
Campbell, Pollak, Huber,Sharma, 2004). Knee osteoarthritis has been shown to be a risk factor
for disability (Hughes, et al., 2004). Patients with Knee osteoarthritis may have limitations which
impair their ability to perform activities of daily living, such as walking, bathing, dressing, use of
toilet, and performing normal household chores (Osteoarthritis, 2000).
Knee osteoarthritis is initially treated pharmacologically to control the joint pain and
preserve functional ability, but frequently, the disease progresses sufficiently that total knee
arthroplasty is indicated (Hawker, Guan, Croxford, Coyte, Glazier, Harvey, Williams, Badley,
2006). Total knee arthroplasty involves removal of the knee joint, which is replaced by a
prosthetic device and commonly involves 4 to 6 weeks of rehabilitation (DeFrances & Hall,
2004; Hawker, et al., 2006). Projections for the year 2016 are 1,046,000 total knee arthroplasties
will be completed (O'Connor & Fehring, 2009), and this number is predicted to increase by
600%, from current levels, to over 3.4 million cases by 2030 (Kurtz, Ong, Lau, Mowat, &
Characteristics of Knee osteoarthritis include decreases in strength (muscle weakness),
fatigue, and functional ability and increases in joint pain (Hurley, 1999; Creamer, 2004).
Progression of these symptoms often leads to decreased mobility, deconditioning, reduced
functional ability, and increased knee pain, all of which decrease the patients’ quality of life.
Topp, Swank, Quesada, Nyland, & Malkani, (2009) have reported that improvements in
functional tasks 3 mo. post total knee arthroplasty can be attributed to a preoperative exercise
intervention (“prehabilitation”). The concept of preparing the body prior to such a stressful event
has been termed “prehabilitation”(Topp, Ditmyer, King, Doherty, & Hornyak, 2002). In the study
by Topp et al. (2009) the group receiving the exercise intervention prior to their surgery (the
prehabilitation group) demonstrated improvements in strength in both the surgical and
nonsurgical quadriceps, while the control group only increased their nonsurgical quadriceps
strength. These preliminary findings suggest the efficacy of prehabilitation exercise on patients’
post surgical functioning. It would be expected that these physical improvements should be
accompanied by increases in the patients’ perceptions of the quality of their lives, but this has not
been assessed. The present study tested whether patients with knee osteoarthritis who engage in
exercise prior to total knee arthroplasty (prehabilitation) reported higher quality of life 3 months
after their surgery than knee osteoarthritis patients who do not engage in prehabilitation.
H1: Knee osteoarthritic patients who engage in exercise prior to total knee arthroplasty
(prehabilitation) will report higher quality of life as measured by ratings of social and physical
functioning, physical and emotional role, general health, mental health, and bodily pain 3 months
after surgery than knee osteoarthritis patients who do not engage in prehabilitation.
H2: Knee osteoarthritic patients who engage in exercise prior to surgery (prehabilitation)
will rate themselves higher on the eight domains representing quality of life 3 months post
surgery than the population norms for patients with osteoarthritis of the knee.
32 subjects were recruited from and individual doctor’s office into the study and
randomized by using a blind draw into one of the two study groups (N = 17 prehabilitation, N =
15 control). Both groups had similar body mass indexes (BMIs) (prehabilitation = 38.8 SD=8.8)
and control = 34.6 SD=7.6). Of these 32 subjects eight (four prehabilitation, four control) were
lost at 5 month follow-up for differing reasons. These reasons included (a) four participants who
required extended inpatient rehabilitation, (b) one with an infection, (c) one who had a cold and
flu symptoms so the latter two were not able to leave their homes and (d) two who did not wish
to continue in the study. A total of 20 participants were reached at the 3 month follow up after
their surgery and completed the SF-36 survey. Two of the returned surveys were not completed
correctly so there were 18 complete surveys returned and available for analysis (prehabilitation =
11, control = 7).
Participants were asked to complete the Standard Form (SF) -36 (Ware & Kosinski,
2001) Health Survey 3 months following their total knee arthroplasty to assess their quality of
The SF-36 is a scale designed as an index of health-related quality of life (McDowell & Newell,
1996; Ware & Kosinski, 2001). This survey has generated normalized scores in general (for
elderly individuals) or specific populations (osteoarthritis patients) (Finch, Brooks, Stratford, &
Mayo, 2002). Responses to the survey can be used to compare the health status of patients with
different conditions and to compare patients with the general population using norms (Finch, et
al., 2002). The SF-36 (Finch, et al., 2002) includes multi-item subscales used to measure the
following eight domains:
Physical functioning (10 items),
Role limitations due to physical health (4 items),
Bodily pain (2 items),
And General health perceptions (5 items),
Vitality (4 items),
Social functioning (2 items),
Role limitations owing to emotional problems (3 items),
And Mental health (5 items).
The eight measures of the SF-36 are combined into two summary scales, the physical
component scale and the mental component scale. The physical component scale and the mental
component scale scores are calculated and presented as summary measure scores, by the
QualityMetric scoring software (Saris-Baglama, Dewey, Chisholm, Plumb, King, Kosinski et.al.
2009). The QualityMetric software was developed to score the SF-36 individual patient’s survey
answers. The physical component scale and mental component scale group mean scores
calculated within the study sample can be compared with mean scores of the 1998 general U.S.
population norms for osteoarthritis patients found in the Physical and Mental Health Summary
Scales manual (Ware & Kosinski, 2001).
This study was a randomized clinical trial. Eligible volunteers were recruited and
provided informed consent approximately 8 weeks prior to their scheduled total knee
arthroplasty surgery. After providing informed consent participants were randomly assigned by a
blind selection to an intervention or a control group. Participants in the control group received
the usual care prior to and following their total knee arthroplasty surgery. Participants assigned to
the intervention or prehabilitation group were instructed to complete three 45 minute bouts of
prehabilitation each week prior to their total knee arthroplasty surgery (Brown, Swank, Quesada,
Nyland, Malkani, Topp, 2010). Following total knee arthroplasty surgery the prehabilitation
group received the same standard postoperative care as the control group.
Both study groups’ background information (age, sex, body mass index, co-morbidities,
etc.) were collected prior to their total knee arthroplasty since it was assumed these variables
would not change over the duration of the study protocol. The prehabilitation group’s adherence
with prehabilitation was collected from each patient during the 8 weeks prior to surgery.
According to their self-reported exercise log sheets the prehabilitation group participated in a
mean16.3 ± 6.0 exercise sessions during their prehabilitation exercise program. The average
length of the prehabilitation episode was 6.3 ± 1.5 weeks and showed a compliance rate of 89%.
The prehabilitation group was given a training booklet which explained the five aspects
of the prehabilitation training program, including warm up, resistance exercises, flexibility
exercises, step training, and cool down (Brown, Brosky, Pariser, & Topp, 2010; . Some parts
(resistance exercises, flexibility exercises, and step training) of this training program have been
shown to improve either performance of functional tasks, knee pain, or the markers of
rehabilitation among older adults ( Topp, Swank, Quesada, Nyland, Malkani, 2009). The
prehabilitation training booklet was based upon previous guidelines for older adults’ exercise
programs ( Topp, Mikesky, Dayhoff, & Holt, 1996).
Participants were requested to complete the prehabilitation training protocol three times
per week, once under the supervision of the project staff at a physical therapy clinic and two
times without supervision at home. All three prescribed sessions included the same warm up,
resistance exercises, flexibility exercises, step training, and cool down. This method of partially
supervising the exercise intervention has previously shown in acceptable adherence by older
participants without making unreasonable demands upon their time and effort to the supervised
exercise sessions (Topp, et al., 1996; Topp, Mikesky, & Thompson, 1998) . Participants in this
group were taught how to record each session of prehabilitation training in an exercise log.
Initially a session of prehabilitation training included approximately five minutes of
warming up, 15 minutes of resistance training exercises, 15 minutes of flexibility exercises, ten
minutes of step training, and five minutes of cool down exercises. The warm-up consisted of
unweighted leg-joint movements to increase blood flow to the muscles of the legs, trunk, and
arms. Following the warm-up, patients completed eight dynamic muscle-strengthening exercises
including squats, ankle dorsi and plantar, hamstring flexion, bicep curls, triceps extensions, chest
press, and seated row. During the first training week, each participant performed one set of 10
repetitions of each strengthening exercise using an elastic resistance band (Theraband®) with
sufficient resistance to produce “moderate” fatigue following the final repetition. Moderate
fatigue would be judged by the therapist as to how much effort the participant was displaying
during the exercise. Individual training progressed under the supervision of the researcher with
the goal that at weeks 7 and 8, each participant performed two sets of 10 repetitions of each
exercise using a Theraband® with sufficient resistance to produce “moderate” fatigue following
the final repetition with a 2 min. rest between sets (approximately 20 min. in all).
Following completion of the resistance training exercises, within each session of
prehabilitation, participants completed six flexibility exercises. Over the entire duration of the
prehabilitation training, flexibility exercises included two repetitions of static stretching of 20
sec. for each flexibility exercise. The flexibility exercises emphasized knee extension and
flexion, hip flexion and extension, trunk extension and flexion, and shoulder flexion, extension
and rotation. Following completion of the flexibility exercises, patients completed three step-
training exercises. These exercises included going up and down a single step forwards and then
sideways to the left and right. During the first week of the prehabilitation program, participants
completed eight repetitions of each of the step exercise using a 2-or 3-in. high step. The number
of repetitions and the height of the step of each of these step exercises were increased over the
prehabilitation intervention. During week 8 of the prehabilitation program, participants
completed 20 repetitions of each of the step exercises using a 4-or 7-in. high step. The cool down
consisted of 5 min. of unweighted leg-joint movements of the muscles of legs, trunk, and arms. If
the participant was unable to complete the initial training or was unable to progress at any week
in the training schedule, an individualized training program was developed consistent with that
participant’s training ability. This individualized prehabilitation training program was intended to
allow the individual to achieve the same level of training for all five components as prescribed in
the prehabilitation exercise booklet. The number of repetitions and sets for all tasks of the
prehabilitation program was recorded in the exercise log.
Survey data were analyzed using the QualityMetric Health Outcomes™ (Saris-Baglama, 2009)
scoring algorithms to obtain subscores. The subscores ranged from 0-100, with higher scores
indicating higher quality of life. Reliability of the survey has been tested for many different
patient groups (McDowell & Newell, 1996).
Analyses included calculation of means and standard deviation of each task for the
sample and inferential statistics to assess the study hypotheses. Independent T tests were
calculated to evaluate whether the prehabilitation group differed from the control group on each
of the SF-36 measures. One sample T scores were calculated to assess the mean differences for
the prehabilitation group or control group from the osteoarthritis population norms found in the
SF – 36 Physical and Mental Health Summary manual (Ware & Kosinski, 2009). All statistics
employed the p<.05 level for statistical significance.
Means and standard deviations for the groups are in Table 2 and indicate the groups
significantly differed only on Physical Functioning with the prehabilitation group scoring
significantly higher than the control group. There were no significant differences on the other 7
domains comprising quality of life.
To address hypothesis 2 the prehabilitation and control groups’ quality of life three
months post total knee arthroplasty scores were compared to established norms for osteoarthritis
using one sample T-Scores. As seen in table 1 the prehabilitation group’s ratings were
significantly higher than the population norms in all eight health-related quality of life measures
while the control group was only significantly higher in the Role Emotional and Mental Health
Table 1 here
Table 2 here
Due to the low statistical power from attrition in the treatment and control groups, the
results are equivocal. In general, the differences were in the expected directions, indicating that
prehabilitation improves ratings across the eight domains used to assess quality of life.
However, the nonsignificant results do not allow generalization and must be followed up by
additional studies with increased sample sizes and sufficient statistical power. However, the one
significant difference (higher ratings for physical functioning after surgery) would appear to be
enough evidence to recommend prehabilitation as treatment prior to surgery. The other set of
comparisons with population norms for knee surgery, indicate that the current prehabilitation
treatment leads to significantly higher ratings on all eight domains three months after surgery,
compared to patients who did not do preoperative exercise.
There are several possible explanations for the differences here, but all of them require
testing using a more specific design and measures. Prehabilitation intervention may increase pre
and post total knee arthroplasty strength and functioning, and thereby promote perceptions of
improved physical functioning at 3 months after the total knee arthroplasty. The prehabilitation
exercise may affect perceptions directly giving the patients more control over their care thus
reporting higher Physical Functioning as a part of quality of life 3 months post surgery. For
example if patients complete a prehabilitation exercise program, this likely will result in strength
and functioning improvements, which in turn, may increase their perceptions of confidence in
their ability to maintain their exercise routine post-rehabilitation. This finding is consistent with
previous research (Brown, et al., 2009; Topp & Page, 2009; Topp, et al., 2009) who
recommended practitioners encourage knee osteoarthritis patients to begin a prehabilitation
exercise program at the earliest possible date before surgery in an attempt to facilitate their
recovery of functional skills during postoperative rehabilitation therapy.
These findings must be interpreted very cautiously because there are a number of
methodological limitations in the design of the study. First, the sample size was too small and
self-selected so it may not represent knee osteoarthritis patients who elect to undergo this
surgery. Second, the multiple comparisons between the groups likely inflated the overall type
one error of the study. Not all patients in the prehabilitation group received the full number of
intervention sessions so a dose-response effect may affect the findings. In the future the rating of
percieved exertion scale should possiblly be used in place of the trainer estimating moderate
fatigue. The prescribed exercises are listed but it may be helpful to include pictures of the
prehabiltation program. Prescribed exercises can be found in a previous article by this author
(Brown, et. al. 2010). More studies should be done to evaluate whether preoperative exercise
intervention affects patients’length of rehabilitation, lowers cost of healthcare services,
improves activities of daily living, shortens time to return to work, improves rated overall
quality of life. Researchers could include exercise interventions which last longer, include more
participants and focus on the intensity of exercise progression to increase participants’ gains in
strength and functional abilities.
It may be hypothesized that extended preoperative prehabilitation exercise programs
would accelerate post operative functional outcomes and improve post operative quality of life.
The duration of the prehabilitation program might be extended to 12 or 24 weeks if the
participants’ scheduled surgery time can be flexible enough. Such extended time and planning
could be followed by greater functional improvements over the duration of the exercise program.
American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. (2000)
Recommendations for the medical management of osteoarthritis of the hip and knee: 2000
update. Arthritis & Rheumatism, 43, 1905-1915.
Brown, K., Brosky, J. A., Pariser, D., & Topp, R. (2010) Preoperative exercise boosts total knee
arthroplasty (TKA) outcomes. Lower Extremity Review, 2, 53-61.
Brown, K., Swank, A., Quesada, P., Nyland, J., Malkani, A., & Topp, R. (2010) Prehabilitation versus
usual care before total knee arthroplasty: a case report comparing outcomes within the same
individual. Physiotherapy Theory And Practice, 26, 399-407.
Brosky, J. A., Finley, M., Topp, R., Killian, C., Pariser, D., & Brown, K. (2011) Effects of a pre-
habilitation program on a pre-operative baseline status and early post-operative outcomes
following total knee arthroplasty. Orthopaedic & Sports Physical Therapy (In Review).
Buckwalter, J. A., & Martin, J. A. (2006) Osteoarthritis. Advanced Drug Delivery Reviews, 58, 150-167.
Centers for Disease Control and Prevention (2001) Prevalence of disabilities and associated health
conditions among adults-United States, 1999. MMWR - Morbidity & Mortality Weekly Report,
Centers for Disease Control and Prevention. (2002) Prevalence of self-reported arthritis or chronic joint
symptoms among adults - United States, 2001. MMWR - Morbidity & Mortality Weekly Report,
Creamer, P. (2004) Current perspectives on the clinical presentation of joint pain in human OA. Novartis
Foundation Symposium, 260, 64-74; discussion 74-68.
Foundation, A. (2009) Osteoarthritis, what is it? Retrieved May 14, 2009, 2009, from
Hughes, S. L., Seymour, R. B., Campbell, R., Pollak, N., Huber, G., Sharma, L., et al. (2004) Impact of
the fit and strong intervention on older adults with osteoarthritis.
Gerontologist, 44, 217-228.
Hurley, M. V. (1999) The role of muscle weakness in the pathogenesis of osteoarthritis.
Rheumatic Diseases Clinics of North America, 25, 283-298.
Lawrence, R. C., Felson, D. T., Helmick, C. G., Arnold, L. M., Choi, H., Deyo, R. A., et al. (2008)
Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part
II. Arthritis & Rheumatism, 58, 26-35.
McDowell, I., & Newell, C. (1996). Measuring Health: A Guide to Rating Scales and
Questionaires (2nd ed.). New York, New York: Oxford University Press.
Petrella, R. J., & Bartha, C. (2000) Home-based exercise therapy for older patients with knee
osteoarthritis: a randomized clinical trial. Journal of Rheumatology, 27, 2215-2221.
Prevention, C. f. D. C. a. (2006) Prevalence of doctor-diagnosed arthritis and arthritis-attributable
activity limitation --- United States, 2003-2005. MMWR - Morbidity & Mortality Weekly Report,
Saris-Baglama, R., Dewey, C., Chisholm, G., Plumb, E., King, J., Kosinski, M., et al.
(2009). QualityMeyric Health OutcomesTM Scoring Software 3.0 (Version XP). Lincoln, R.I.,
USA: QualityMetric Incorporated.
Topp, R., Mikesky, A., Dayhoff, N. E., & Holt, W. (1996) Effect of resistance training on strength,
postural control, and gait velocity among older adults. Clin Nurs Res, 5, 407-427.
Topp, R., Mikesky, A., & Thompson, K. (1998) Determinants of four functional tasks among older
adults: an exploratory regression analysis. J Orthop Sports Phys Ther, 27, 144-153.
Topp, R., Woolley, S., Pifer, M., Khuder, S., Hornyak, J., & Kahaleh, B. (2001) The effect of strength
training on pain during functioning among patients with OA of the knee. Paper presented at the
Midwest Nursing Research Society's Annual Conference, Cleveland, OH.
Topp, R., Ditmyer, M., King, K., Doherty, K., & Hornyak, J. (2002) The effect of bed rest and potential
of prehabilitation on patients in the intensive care unit. AACN Clinical Issues, 13, 263-276.
Topp, R., Swank, A., Quesada, P., Nyland, J., & Malkani, A. (2009) The Effect of Prehabilitation
Exercise on Strength and Functioning After Total Knee Arthroplasty. American Academy of
Physical Medicine and Rehabilitation, 1, 729-735.
Ware, J., & Kosinski, M. (2001) SF-36 Physical & Mental Health Summary Scales: a manual for users
of Version 1. (2nd ed.) Lincoln, RI: QualityMetric, Inc.
Comparison of Prehab and Control group means to population norm means 3 months post
Total Knee Arthroplasty using One Sample T-Score (N= PRE 11, CON 7)
T p value
(p < .05)
Bodily Pain 39.67±9.91 Control
Note * indicates significant difference @ P < .05
Comparison of Prehab and Control 3 month post Total Knee Arthroplasty using Independent
Variable GroupMean (SD)tP
Physical Functioning Control 39.3 (30.2) 2.3.04*
Prehab 66.4 (20.7)
Role-Physical Control 64.3 (28.3)1.0.33
Bodily Pain Control 47.6 (22.8)1.2 .23
General Health Control 62.4 (23.5)1.0 .33
Vitality Control59.8 (31.0) .04.97
Social Functioning Control66.1 (37.3)1.4.18
Role- Emotional Control79.8 (30.4) 1.6.13
Mental Health Control 81.4 (20.8).01.99