Clinical and cost-effectiveness of physiotherapy interventions following total hip replacement: a systematic review and meta-analysis

Abstract

To examine the reported clinical and cost-effectiveness of physiotherapy interventions following total hip replacement (THR). A systematic review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). MEDLINE, CINAHL, AMED, Scopus, DARE, HTA, and NHS EED databases were searched for studies on clinical and cost-effectiveness of physiotherapy in adults with THR published up to March 2020. Studies meeting the inclusion criteria were identified and key data were extracted. Risk of bias was assessed using the Cochrane Risk of Bias Tool and a Consolidated Health Economic Evaluation Reporting Standards (CHEERS). Data were summarised and combined using random-effect meta-analysis. A total of 1263 studies related to the aim of the review were identified, from which 20 studies met the inclusion criteria and were included in the review. These studies were conducted in Australia (n = 3), Brazil (n = 1), United States of America (USA) (n = 2), France (n = 2), Italy (n = 2), Germany (n = 3), Ireland (n = 1), Norway (n = 2), Canada (n = 1), Japan (n = 1), Denmark (n = 1), and United Kingdom (UK) (n = 1). The duration of follow-up of the included studies was ranged from 2 weeks to 12 months. Physiotherapy interventions were found to be clinically effective for functional performance, hip muscle strength, pain, and range of motion flexion. From the National Health Service perspective, an accelerated physiotherapy programme following THR was cost-effective. The findings of the review suggest that physiotherapy interventions were clinically effective for people with THR. However, questions remain on the pooled cost-effectiveness of physiotherapy interventions, and further research is required to examine this in patients with THR. Future studies are required to examine the cost-effectiveness of these interventions from patients, caregivers, and societal perspectives.
Registration Prospero (ID: CRD42018096524).

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Rheumatology International (2020) 40:1385–1398
https://doi.org/10.1007/s00296-020-04597-2
SYSTEMATIC REVIEW
Clinical andcost‑eectiveness ofphysiotherapy interventions
followingtotal hip replacement: asystematic review
andmeta‑analysis
FrancisFatoye1 · J.M.Wright1 · G.Yeowell1 · T.Gebrye1
Received: 20 February 2020 / Accepted: 4 May 2020 / Published online: 25 May 2020
© The Author(s) 2020
Abstract
To examine the reported clinical and cost-effectiveness of physiotherapy interventions following total hip replacement (THR).
A systematic review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA). MEDLINE, CINAHL, AMED, Scopus, DARE, HTA, and NHS EED databases were searched for studies on
clinical and cost-effectiveness of physiotherapy in adults with THR published up to March 2020. Studies meeting the inclu-
sion criteria were identified and key data were extracted. Risk of bias was assessed using the Cochrane Risk of Bias Tool and
a Consolidated Health Economic Evaluation Reporting Standards (CHEERS). Data were summarised and combined using
random-effect meta-analysis. A total of 1263 studies related to the aim of the review were identified, from which 20 studies
met the inclusion criteria and were included in the review. These studies were conducted in Australia (n = 3), Brazil (n = 1),
United States of America (USA) (n = 2), France (n = 2), Italy (n = 2), Ger many (n = 3), Ireland (n = 1), Norway (n = 2), Canada
(n = 1), Japan (n = 1), Denmark (n = 1), and United Kingdom (UK) (n = 1). The duration of follow-up of the included stud-
ies was ranged from 2weeks to 12months. Physiotherapy interventions were found to be clinically effective for functional
performance, hip muscle strength, pain, and range of motion flexion. From the National Health Service perspective, an accel-
erated physiotherapy programme following THR was cost-effective. The findings of the review suggest that physiotherapy
interventions were clinically effective for people with THR. However, questions remain on the pooled cost-effectiveness of
physiotherapy interventions, and further research is required to examine this in patients with THR. Future studies are required
to examine the cost-effectiveness of these interventions from patients, caregivers, and societal perspectives.
Registration Prospero (ID: CRD42018096524).
Keywords Cost-effectiveness· Physiotherapy· Total hip replacement· Systematic review
Introduction
Osteoarthritis (OA) is one of the major chronic diseases, and
a primary cause of pain and disability among adults [1, 2].
Hip and knee OA ranked as the 11th highest contributor to
global disability and 38th highest in disability-adjusted life
years (DALYs) [3]. Between 1990 and 2010, the global age-
standardised prevalence of hip OA was 0.85% [95% uncer-
tainty interval (UI) 0.74–1.02%]. For people age ≥ 60years,
the prevalence of radiographic hip OA (7%) is less com-
mon than OA of the knee (37%) [4]. The prevalence of OA
of the hip is higher in females than males [3]. Due to the
severe long-term pain and disability resulting from OA hip,
its clinical and economic impact is substantial. People with
OA of the hip have difficulty with functional activities as
well as high levels of depression and anxiety [5, 6]. The total
costs of OA in the United States of America (USA), France,
United Kingdom (UK), Canada, and Australia accounted for
between 1 and 2.5% of the Gross National Product (GNP) for
these countries [7]. In contrast, the cost of OA in Hong Kong
accounted for 0.28% of the GNP which was between £253
million and £308 million [7]. From this, the annual direct
and indirect costs per person ranged from £384 to £883 and
£261 to £525, respectively [8].
Rheumatology
INTERNATIONAL
* Francis Fatoye
f.fatoye@mmu.ac.uk
1 Department ofHealth Professions, Faculty ofHealth,
Psychology, andSocial Care, Manchester Metropolitan
University, Brooks Building, 53 Bonsall Street,
ManchesterM156GX, UK
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1386 Rheumatology International (2020) 40:1385–1398
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Pharmaceutical management, non-pharmaceutical ther-
apies, and surgical procedures are advocated by clinical
guidelines for managing OA of the hip [9]. Total hip replace-
ment (THR) is a common orthopaedic procedure for OA of
the hip when conservative management fails [10]. Evidence
showed that around 2.5 million (1.4 million women and
1.1 million men) Americans are living with a THR [11].
Current clinical guidelines recommend that non-pharma-
ceutical therapies including access to appropriate informa-
tion to enhance understanding of the condition; activity and
exercise; positive behavioural changes; manipulation and
stretching; and transcutaneous electrical nerve simulation
for patients following a THR for hip OA [12].
Previous systematic reviews have evaluated the effec-
tiveness of physiotherapy interventions following THR;
however, they reported conflicting findings [13, 14]. Lowe
etal. [13] indicated that physiotherapy exercise following
THR has the potential to benefit patients. On the other hand,
Wijnen etal. [14] identified that there was limited evidence
to support the effectiveness of physiotherapy exercise fol-
lowing THR. Furthermore, there are no reviews that have
been conducted on the cost-effectiveness of physiotherapy
interventions following THR. Therefore, the purpose of
this review was to investigate the clinical and cost-effec-
tiveness of physiotherapy interventions following THR,
which could be used to inform clinical practice and patient
decision-making.
Methods
Search protocol andregistration
This systematic review used the Preferred Reporting Items
for Systematic Reviews and Meta-Analysis (PRISMA), a
technique that addresses the eligibility, data sources, selec-
tion of studies, data extraction, and data analysis as a report-
ing guideline [15]. This review was registered on PROS-
PERO, with registration number, CRD: CRD42018096524.
Data sources
A search of literature for published and unpublished studies
was conducted to MEDLINE, Cumulative Index to Nursing
and Allied Health Literature (CINAHL), AMED, Scopus,
Database of Abstracts of Reviews of Effects (DARE), Health
Technology Assessment (HTA) database, and the National
Health Service Economic Evaluation Database (NHS EED)
in the last 2 decades. The search terms used were hip,
replace*, “total hip replacement’’, arthroplasty, “total hip
arthroplasty’’, “therapeutic exercise’’, training, “functional
training’’, “home physical training’’, “joint mobilization’’,
exercise, physical therapist, therap*, treatment, medicine,
muscle*, quadriceps*, strength, function, kinesiotherap*,
rehabilitation, physiotherapy, “exercise therapy’’, “physical
therapy’’, effectiveness, “clinical effectiveness’’, cost, value,
money, expenditure, QALY, HRQoL, “healthcare costs’’,
economics, “cost-effectiveness analysis’’, “cost-utility analy-
sis’’, and “cost–benefit analysis’’. These search terms were
combined using conjunctions such as “AND’’ and “OR’’.
Search strategy
The Population, Intervention, Comparison, Outcome (PICO)
framework was utilized in the development of the search
strategy with search terms and limits relating to population
of interest and intervention. The inclusion criteria were stud-
ies that: included patients (mean age ≥ 18years) following
THR for hip OA; assessed the clinical or cost-effectiveness
of different forms of physiotherapy compared to other forms
of physiotherapy or no intervention; reporting results of ran-
domized-controlled and retrospective/prospective trials. In
this review, physiotherapy interventions covered a range of
techniques including massage, passive stretching, functional
rehabilitation, interdisciplinary rehabilitation, exercise,
physical training, acupuncture, spinal manipulation, advice,
yoga, cognitive behavioural therapy, and martial arts. The
economic evaluation (cost-effectiveness analysis, cost–ben-
efit analysis, and cost–utility analysis) carried out alongside
randomized-controlled trials and retrospective cohort study
were included.
The outcomes of interest in this review included: pain,
function, muscle strength, clinical and motor performance,
activities of daily living, and health-related quality of life.
To be included for the economic evaluation, studies had to
relate the costs of the interventions to the effects of the inter-
ventions. Systematic reviews, narrative literature reviews,
studies of non-English language, and conference papers were
excluded. Further exclusion criteria were abstract unavail-
able, studies not yet fully completed, and studies carried out
with THR patients mean aged < 18years.
Duplicates were removed electronically and manually.
Two independent researchers (TG and FF) were involved in
screening the title and abstract of each study. Full-text arti-
cles were obtained and were excluded if they did not meet
the inclusion criteria. Any disagreement in study selection
was resolved through discussion and consultation with other
members of the team (GY and JMW) where necessary.
Data extraction andrisk ofbias assessment
One of the researchers extracted data (TG) and the three
members of the team cross-checked the extracted data (FF,
GY, and JMW). The following data were extracted: author
and date of the study, the location/country, type of partici-
pant, and the number of participants involved in the study.
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1387Rheumatology International (2020) 40:1385–1398
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The mean age, percentage of male and female participants
who received the interventions and the control arm, and the
type and the duration of the physiotherapy interventions
were also extracted from each study. Furthermore, data
regarding outcome measures, including the primary and
secondary health outcomes, resource use and cost, and the
cost-effectiveness ratio (ICER) were extracted.
Risk of bias for studies that met the inclusion criteria for
the clinical effectiveness was assessed using the criteria of
the Cochrane Risk of Bias Tool [16]. The Cochrane Col-
laboration’s tool aims to make the process clearer and more
accurate, and it covers six domains of bias such as selection
bias, performance bias, detection bias, attrition bias, report-
ing bias, and other bias. Studies were considered high risk
of bias when one or more of the key domains had unclear or
high risk of bias [16].
The Consolidated Health Economic Evaluation Reporting
Standards (CHEERS) statement was also used as a reporting
guideline for the included cost-effectiveness studies [17].
Twenty-four items were addressed in six categories, which
include title and abstract, introduction, methods, results, dis-
cussion, and others. Cost-effectiveness studies were rated
positive (√) if they reported in full, and negative (x) if they
did not fulfil the listed criteria in the CHEERS statement.
For those studies that have partial or inconclusive informa-
tion, they were labelled as partial (P). A total score of 1 was
assigned if they fulfilled the requirement of reporting for
that Item completely, 0 for not reporting and 0.5 for partial
reporting. The maximum score for an article that reported
completely all information was 24.
Data analysis
A descriptive synthesis and meta-analysis of the extracted
data is presented. This study considered a weighting proce-
dure for the clinical effectiveness of physiotherapy interven-
tions as well as its cost-effectiveness of the included studies
only when the procedure for combining data from multiple
studies was satisfied. The continuous outcomes measures
were expressed as a weighted mean difference with 95%
confidence intervals. To summarise the findings across the
studies, a statistical significance of p < 0.05 was set. Due to
the statistical evidence of heterogeneity across the studies,
a random-effects model was chosen [15].
Results
From the literature search, 1263 potentially relevant stud-
ies were identified. Of these, 181 duplicates were removed.
The title and abstract of the remaining 1082 studies were
screened for eligibility. The full texts of 44 remaining stud-
ies were reviewed. Overall, 20 studies were eligible and
included in this review. A summary is provided in the sys-
tematic review flow diagram (Fig.1).
Study characteristics
Eighteen studies assessed the clinical effectiveness of
physiotherapy interventions and two studies examined cost-
effectiveness of the interventions using information from
1400 and 108 patients following THR, respectively. The
duration of follow-up of patients in the included studies
ranged from 2weeks to 12months. The mean age of the
participants in the intervention and control groups ranged
from 46.93–68.6years and 55.5–68.58years, respectively.
The geographical locations of these studies were: Australia
(n = 3), Brazil (n = 1), USA (n = 2), France (n = 2), Italy
(n = 2), Germany (n = 3), Ireland (n = 1), Norway (n = 2),
Canada (n = 1), Japan (n = 1), Denmark (n = 1), and UK
(n = 1) (Table1).
Risk ofbias
The assessment of risk of bias of the included clinical effec-
tiveness studies is presented in Table2. All the included
studies have unclear or high risk of bias within at least one
domain, and thus, no studies have achieved a low risk of
bias. Except two studies that were assigned high risk of bias
[18] and unclear risk of bias [19] for reporting bias, most of
the included studies achieved low risk of bias for the report-
ing and other bias. Thirteen and 16 out of 18 studies had
high risk of bias for treatment allocation and blinding of
participants of intervention. Sixteen out of eighteen studies
had low risk of bias and two studies [20, 21] had unclear risk
of bias for blinding outcome assessment. Five of eighteen
studies were assigned unclear attrition bias, and the remain-
ing studies had low risk of bias.
In relation to the two included cost-effectiveness stud-
ies [22, 23], the CHEERS scores suggest that the methodo-
logical quality of the included studies had adequate quality
(Table4).
Eectiveness ofphysiotherapy interventions
The effectiveness of physiotherapy interventions was
assessed in the included studies.
Acute hospital length ofstay
Haas etal. [19] investigated the effect of an acute weekend
physiotherapy service compared to no physiotherapy service
following THR. Weekend physiotherapy service was associ-
ated with significantly increased odds of discharge directly
home [odds ratio 3.151 (1.039–9.555)] and improved mobil-
ity [coefficient 4.301 (1.500–7.101)]. However, patients in
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1388 Rheumatology International (2020) 40:1385–1398
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the intervention group perceived hospitalisation as less help-
ful and acute length of stay was longer compared to patients
without physiotherapy services at the weekend. Overall,
weekend physiotherapy service was beneficial on discharge
destination and patient mobility.
Health‑related quality oflife
Three studies reported the impact of physiotherapy interven-
tions on health-related quality of life (HRQoL) [21, 24, 25].
The Euroqol visual analogue scale [21, 24] and a self-admin-
istered HRQoL questionnaire [25] were used to assess the
quality of life of THR patients. The comparative advantage
of a targeted home- and centre-based exercise programme
over unsupervised home-based exercise group were exam-
ined in patients following THR [25]. Patients who received
the targeted home- and centre-based exercise programme
achieved significant improvements (p < 0.05) in HRQoL.
On the other hand, no clinically significant difference was
observed between patients following THR in the groups who
received inpatient and sports rehabilitation compared with
control on HRQoL at 1year [21, 24].
Function
The effects of physiotherapy interventions on functional
performance in patients following THR were assessed in
six studies [20, 26–30]. The findings of these studies dem-
onstrated that hydrotherapy, home exercise programme,
physiotherapy-led functional exercise program, a 6-week
arm exercise programme, an arm-interval exercise pro-
gram, in-hospital program based on task-oriented exer-
cises, and a targeted home and centre exercise programme
were effective in improving the functional performance of
Records identified through
databases searching (n = 1263)
(Medline 607, CINAHL 86,
AMED 122, NHSEED 97 , HTA 125,
DARE 67, Scopus 159)
Screening
Included
Eligibility Idenficaon
Records after duplicates
removed
(n = 1082)
Potential citations for
screening
(n = 1082 )
Records excluded based
on titles/abstracts
(n = 1038)
Full-text articles assessed for
eligibility
(
n = 44
)
Full-text articles excluded, with
reasons (n = 24)
Preoperative intervention (n = 9)
Protocol only (n = 5)
Not physiotherapy (n = 7)
Not relevant outcomes (n = 3)
Studies included in data
synthesis
(n =20)
Duplicates
(n =181)
Fig. 1 Systematic review flow diagram
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1389Rheumatology International (2020) 40:1385–1398
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Table 1 Summary of the characteristics of the studies reporting the clinical effectiveness
Reference/country/dura-
tion Participants Interventions Control Effectiveness
Number Mean (SD) age % of female
Umpierres etal. [31]/
Brazil/2weeks Total = 106
Int = 54; Cot = 52 Total = 61.4 (15.0)
Int = 61.8 (15.6);
Cot = 60.9 (14.5)
Int = 51.9
Cot = 55.8 Verbal instructions and
demonstrations associ-
ated with daily exercise
practice guided by a
physiotherapist
Verbal instructions and
physiotherapy exercise
demonstrations
Flexion: Int = 4.3 (0.1);
p = < 0.001
Cot = 3.9 (0.7); p = < 0.001
MD = 0.807 [0.411, 1.204,
p = 0.00]
Extension: Int = 4.5 (0.1);
p = 0.004
Cot = 4.1 (3.1); p = < 0.001
MD = 0.184 [−
0.197,0.566, p = 0.34]
Motor performance,
Int = 8.6 (0.1); p = 0.03
Cot = 8.3 (0.1), p = 0.16
MD = 3 [2.44, 3.55,
p = 0.00]
Clinical (pain), Int = 4.1
(0.1); Cot = 3.4 (0.1)
Haas etal. [19]/Aus-
tralia/1year Total = 276
Int = 130; Cot = 146 Int = 67.77 (10.62)
Cot = 68.58 Int = 58
Cot = 62 Acute weekend physi-
otherapy service No physiotherapy Int: Utility (Median,
IQR) = 0.54 (0.31, 0.67)
Pain (median, IQR) = 6 (5,
7); Cot: Utility = 0.55
(0.30, 0.70); Pai n = 5
(5, 7)
Naylor etal. [24]/Aus-
tralia/1year Total = 246
Int = 123; Cot = 123 Int = 67.8 (10)
Cot = 66.9 (10.6) Int = 36.8
Cot = 31.7 Inpatient physiotherapy No physiotherapy Int: (3months, 1year):
Oxford Hip Score (OHS)
median (IQR) = 46 (41,
48); 48 (46 48) p = 0.6;
EuroQol scale, Median
(IQR) = 85 (80, 95); 85
(75, 95) p = 0.09
Cot: (3months, 1year):
Oxford Hip Score: 46
(41, 48); 48 (46, 48);
EuroQol = 90 (80 95); 90
(80, 95)
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1390 Rheumatology International (2020) 40:1385–1398
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Table 1 (continued)
Reference/country/dura-
tion Participants Interventions Control Effectiveness
Number Mean (SD) age % of female
Trudelle-Jackson
and Smith [36]/
USA/8weeks
Total = 34
Int = 18; Cot = 16 59.5 (11.2) N/A Sitting: sit to stand.
Standing: unilateral
heel raises, partial
knee flexion, single leg
stand, knee raises with
alternate arm raises,
side and back leg raises,
unilateral pelvic raising,
and lowering. Repeti-
tion rate (RR) = 15, 3 to
4 × week for 8weeks.
If able RR increased
to 20 at 1st follow-up
(2weeks) and 2 × 20 at
2nd follow-up (8weeks)
Gluteal muscle sets, ham-
strings and quadriceps
sets, ankle pumps, heel
slides
Hip abduction in supine,
internal rotation, and
external rotation. RR as
for intervention group
Flexors
Int: Hip Questionnaire-12
(median, range) = 16 (12,
38)
Cot: Hip Questionnaire-12
(median, range) = 17.5
(12, 33)
Jan etal. [20]/
USA/12weeks Total = 53
Int = 26
Cot = 27
Int = 58.8 (12.9)
Cot = 57.0 (12.8) Int = 34
Cot = 37 Patients underwent a
12-week home program
that included hip
flexion, range of motion
exercises for both hip
joints; strengthening
exercises for bilateral
hip flexors, extensors,
and abductors; and a
30-min walk every day
No training Flexors, Int = 57.5 (22.3);
Cont = 50.8 (21.2)
MD = 0.31 [− 0.23, 0.85,
p = 0.26]
Function score, Int = 13.1
(0.6); p < 0.05
Cot = 12.0 (1.4),
MD = 0.922 [0.356, 1.49,
p = 0.001]
Husby etal. [37]/Nor-
way/5weeks Total = 24 Int = 12
Cot = 12 Int = 58 (5)
Cot = 56 (8) Int = 58
Cot = 66 Patients performed maxi-
mal strength training
(STG) in leg press and
abduction with the oper-
ated leg only five times
a week for 4weeks in
addition to the conven-
tional rehabilitation
program
Patients received super-
vised physical therapy
three-to-five times a
week for 4weeks
1-repetition maximum
increased in the bilateral
leg press (p < 0.002) and
in the operated leg sepa-
rately (p < 0.002) in the
intervention compared
with the control
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1391Rheumatology International (2020) 40:1385–1398
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Table 1 (continued)
Reference/country/dura-
tion Participants Interventions Control Effectiveness
Number Mean (SD) age % of female
Monaghan etal. [26]/
Ireland/18weeks Total = 63 Int = 32
Cot = 31 Int = 68(8); Cot = 69 (9) Int = 37
Cot = 26 The participants were
taught 12 exercises by
the supervising physi-
otherapist. They also
attended classes twice
weekly for 6weeks,
and were not given any
additional exercises as a
home exercise program
All patients were advised
to walk daily with
crutches until review by
the orthopaedic surgeon
at 6weeks, increasing
the distance gradually
to approximately 1 mile
after 1month
Mean % at week 18
(Int vs Cot) WOMAC
(pain) = − 0.81 (− 1.8 to
0.2), p = 0.1; WOMAC
(stiffness) = − 0.44 (− 1.2
to − 0.28); p = 0.2;
WOMAC functio n = − 4.0
(− 0.71 to 1.0); p = 0.04
Winther etal. [35]/Nor-
way/12months Total = 63
Int = 31
Cot = 29
Int = 61
Cot = 66 Int = 54
Cot = 52 Patients were trained
at 85–90% of their
maximal capacity in leg
press and abduction of
the operated leg (4 × 5
repetitions), 3 times a
week at a municipal
physiotherapy institute
up to 3months postop-
eratively
Patients were followed
a training program
designed by their
respective physiothera-
pist, mainly exercises
performed with low or
no external loads.
Int. patients were substan-
tially stronger in leg press
and abduction than Cot
Okoro etal. [18]/
UK/6weeks Total = 49 Int = 25
Cot = 24 Int = 65.15 (9.06)
Cot = 66.3 (11.02) Int = 15/25, Cot = 10/24 Patients were instructed to
perform a range of rep-
etitions (0–3, 4–6, 7–10)
depending on their
initial physiotherapy
assessment and then to
progress, when able to,
to achieve progressive
overload. Subjects were
encouraged to exercise
at least 5 times a week
Home-based functional
non-progressive resist-
ance training exercises
that were geared
towards getting the
patients safely mobile
Maximal voluntary
contraction of the oper-
ated leg quadriceps
(MVCOLQ); MD = 26.50
(8.71) p = 0.001; timed
up and go (TUG);
MD = − 1.44 (0.45);
p = 0.0001
Stair Climb Per-
formance (SCP);
MD = − 3.41(0.80);
p = 0.0001
6min Walk Test (6MWT);
MD = 45.61 (6.10)m;
p = 0.0001
Maire etal. [27]/France/6
weeks Total = 14 Int = 7
Cot = 7 N/A N/A Muscular strength, range
of motion, aquatics,
walking 2h/day). In
addition, this group
undertook an arm-inter-
val exercise program
with an arm ergometer
Muscular strength, range
of motion, aquatics,
walking 2h/day
Int: WOMAC (pain) = −
100; p < 0.05; WOMAC
(physical function) = −
45; p < 0.05 Cot:
WOMAC (pain) = − 72;
p < 0.05 WOMAC
(physical function) = − 26
p < 0.05
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1392 Rheumatology International (2020) 40:1385–1398
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Table 1 (continued)
Reference/country/dura-
tion Participants Interventions Control Effectiveness
Number Mean (SD) age % of female
Beaupre etal. [32]/Can-
ada/12months Total = 21 Int = 11
Cot = 10 Int = 51.7 (8.3) Cot = 55.9
(9.9) Int = 64%
Cot = 30% Received out-patient
rehabilitation program.
Sessions were approxi-
mately two and one half
hours in durations and
included both aquatic
and land-based com-
ponents with a focus
on strength and gait
retraining
Usual care Mean % from 6weeks
to 4months postop-
erative Int: hip flexion
(SD) = 73.8 (50.1)
p = 0.69; hip exten-
sion (SD) = 50.5 (26.1);
p = 0.78; Cot: hip flexion
(SD) = 39.8 (64.1),
p = 0.69; hip exten-
sion (SD) = 30.5 (67.3),
p = 0.78
Nankaku etal. [33]/
Japan/4weeks Total = 28
Int = 14
Cot = 14
Int = 60.5(6.4)
Cot = 60.8 (7.5) Int = 50
Cot = 50 Exercise program of hip
external rotator was
performed and super-
vised by an experienced
physical therapist.
Usual care Int, hip pain; p = 0.05; hip
flexion angle, p = 0.05;
hip abduction angle,
p = 0.05
Cot, hip pain; p = 0.05; hip
flexion angle, p = 0.05;
hip abduction angle,
p = 0.05
Beck etal. [21]/Ger-
many/12months Total = 160
Int = 80
Cot = 80
Int = 59®
Cot = 61.9®Int = 52.5
Cot = 63.8 Intensive exercise
therapy: walking slowly
in circles, fast walking,
leg axis training from
various start positions,
correct sitting, and team
circles games
No exercise therapy Int WOMAC (pain) = 100,
Cot = 95; p = 0.003
Int EQ-5D (VAS) = 90;
Cot = 85; p = 1.00
Int WOMAC (stiff-
ness) = 87.5; Cot = 100;
p = 0.373
Maire etal. [28] /
France/12months Total = 14 Int = 7
Cot = 7 N/A N/A Muscular strength, range
of motion, aquatics,
walking 2h/day). In
addition, this group
undertook an arm-inter-
val exercise program
with an arm ergometer
Muscular strength, range
of motion, aquatics,
walking, 2h/day
Int: WOMAC (physical
function) = 5 (3–15);
p < 0.05; Walking
distance (m) = 486
(343–584) Cot: WOMAC
(physical function) = 14
(4–18); walking dis-
tance = 398 (333–482)
Galea etal. [25]/Aus-
tralia/8weeks Total = 23 Int = 11
Cot = 12 Int = 68.6 (9.7)
Cot = 66.6 (7.9) Int = 8/11 Cot = 8/12 Advice about how to pro-
gress the exercises. The
maximum time period
for each exercise was
5min, which included a
rest period if required
Patients were not given
any further instruction
on progressing or modi-
fying the exercises
Int: WOMAC (pain),
p = 0.07; stiffness,
p = 0.26; quality of life,
0.02; Cot: WOMAC
(pain), p = 0.08; stiffness
p = 0.34; quality of life,
p = 0.02
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1393Rheumatology International (2020) 40:1385–1398
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Table 1 (continued)
Reference/country/dura-
tion Participants Interventions Control Effectiveness
Number Mean (SD) age % of female
Giaquinto etal. [29]/
Italy/6months Total = 64 Int = 31
Cot = 33 Int = 70.6 (8.4);
Cot = 70.1 (8.5) Int = 66.6
Cot = 67.7 The hydrotherapy group
was treated in a special
pool for 40min after
20min of passive joint
motion, during which
participants were
prepared
Patients received land
therapy followed by a
‘neutral’ massage on the
hip scar for 20min
Int: WOMAC (pain),
p < 0.01; WOMAC
(stiffness), p < 0.01;
WOMAC (function)
p < 0.01 Cot: WOMAC
(pain), p = 0.08; stiff-
ness, p = 0.58; function,
p = 0.01
Monticone etal. [30]/
Italy/12months Total = 100
Int = 50
Cot = 50
Int = 69.5 (7.5);
Cot = 68.8 (8.1) Int = 32/50
Cot = 28/50 Performed task-oriented
exercises, such as mov-
ing from a sitting to a
standing position, etc.
Sessions of stationary
cycling were added to
optimise hip strength
and mobility
Performed open kinetic
chain exercises WOMAC (function),
p < 0.001; WOMAC
(pain) p < 0.001;
WOMAC (stiffness)
p < 0.001
Mikkelsen etal. [34]/
Denmark/10weeks Total = 62
Int = 32 Cot = 30 Int = 64.8 (8); Cot = 65.1
(10) Int = 44
Cot = 40 Patients warmed up on
a stationary bike for
5–10min and then per-
formed unilateral patient
resistance training of
the operated leg for
30–40min. One-to-one
supervision by physi-
otherapists
Patients were recom-
mended to perform one
set of ten repetitions
twice a day in their
maximum possible
range of motion
Ten weeks, maxi-
mum walking speed
Int = 11.08, Cot = 11.99,
p = 0.008; hip abduc-
tion strength, Int = 1.03
(0.3), Cot = 1.03 (0.3);
p = 0.26; hip flexion
strength, Int = 1.25 (0.3);
Cot = 1.32 (0.4); p = 0.29
Int intervention, Cot control, MD standard mean difference, USA United States of America, % percentage, WOMAC Western Ontario and McMaster Universities (WOMAC) Osteoarthritis
Index, ® Median
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1394 Rheumatology International (2020) 40:1385–1398
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patients following THR. One of the studies [20] used Har-
ris Hip Score to measure function, whereas the remaining
five studies [26–30] used Western Ontario and McMaster
Universities (WOMAC) Osteoarthritis Index.
Muscle strength
Six studies investigated the effects of physiotherapy
interventions on hip flexors muscle strength following
THR [26, 31–35]. Compared to patients assigned into
the control, improved hip muscle strength was observed
in patients following THR who received home exercise
programme, postoperative exercise programme, exercise
programme focussing on hip external rotator muscle,
supervised progressive resistance training, rehabilitation
and muscle strength training.
Range ofmovement
Range of motion flexion data suitable for meta-analysis were
available from two studies that compared physiotherapy
and no physiotherapy interventions [20, 31]. As it is dem-
onstrated in Table3, there was evidence that physiotherapy
interventions significantly improved range of motion flexion
with a standard difference in means 0.634 (95% CI 0.170,
1.098, p = 0.007).
Pain
The effectiveness of physiotherapy on hip pain following
THR was examined in seven studies conducted across dif-
ferent countries [20, 26, 27, 29–31, 33]. The findings of five
of the studies [27, 29–31, 33] showed that hip pain was sig-
nificantly improved for those patients following THR in the
Table 2 Summary of risk of bias assessment
+ 1, low risks of bias, − 1, high risk of bias, ?, unclear risk of bias
Random
sequence gen-
eration (selection
bias)
Allocation
concealment
(selection bias)
Blinding of
participants and
personnel (per-
formance bias)
Blinding of out-
come assessment
(detection bias)
Incomplete
outcome data
(attrition bias)
Selective report-
ing (reporting
bias)
Other bias
Umpierres etal.
[31]+ 1 + 1 − 1 + 1 + 1 + 1 + 1
Haas etal. [19] − 1 − 1 − 1 + 1 + 1 ?+ 1
Naylor etal. [24] − 1 − 1 − 1 + 1 + 1 + 1 + 1
Trudelle-Jackson
and Smith [36]? − 1 1 + 1 ?+ 1 + 1
Jan etal. [20] − 1 − 1 − 1 ? + 1 + 1 + 1
Husby etal. [37]+ 1 − 1 − 1 + 1 ?+ 1 + 1
Monaghan etal.
[26]+ 1 + 1 − 1 + 1 + 1 + 1 + 1
Okoro etal. [18]+ 1 + 1 −+ 1 ? − 1 + 1
Maire etal. [27] ? − 1 − 1 + 1 + 1 + 1 + 1
Beaupre etal.
[32]+ 1 − 1 1 + 1 + 1 + 1 + 1
Nankaku etal.
[33]+ 1 − 1 − 1 + 1 + 1 + 1 + 1
Maire etal. [28]+ 1 − 1 − 1 + 1 + 1 + 1 + 1
Galea etal. [25]+ 1 − 1 − 1 + 1 + 1 + 1 + 1
Giaquinto etal.
[29]? − 1 − 1 + 1 ?+ 1 + 1
Monticone etal.
[30]+ 1 + 1 − 1 + 1 + 1 + 1 + 1
Mikkelsen etal.
[34]+ 1 + 1 − 1 + 1 + 1 + 1 + 1
Winther etal.
[35]? − 1 − 1 ? + 1 + 1 + 1
Beck etal. [21] ? − 1 − 1 + 1 ?+ 1 + 1
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1395Rheumatology International (2020) 40:1385–1398
1 3
intervention group compared to control. Whereas two stud-
ies [26, 31] reported that patients following THR received
home- and centre-based exercise and physiotherapy super-
vised functional exercise programme showed no significant
improvement in hip pain.
Clinical andmotor performance
One study [31] reported the effect of physiotherapy inter-
ventions on clinical and motor performance. The patients
(n = 54) received rehabilitation assisted by the multidisci-
plinary hip group with the presence of physiotherapy pro-
fessionals. After the 15th postoperative day after discharge,
those in the intervention groups showed greater improve-
ments in clinical (gait, pain, and mobility) and motor per-
formance (gait and pain) (p < 0.001) compared with those
patients supported without physiotherapy professionals.
Those in the intervention group have also showed signifi-
cantly greater improvements in muscle strength force (flex-
ion, p < 0.001; extension, p < 0.001; abduction, p = 0.003;
internal rotation, p < 0.001; external rotation, p < 0.001)
compared to the non-intervention group.
Cost‑eectiveness ofphysiotherapy interventions
Two of the included studies that compared accelerated physi-
otherapy with standard physiotherapy [22] and in-patient
rehabilitation with out-patient physiotherapy [23] have
conducted economic evaluation in patients of OA following
THR (Table4). The design of the studies was a cost–util-
ity analysis alongside randomized-controlled trial [22] and
retrospective cohort study [23]. From the National Health
Service (NHS) and healthcare insurer perspective, a £504
per patient [22] and € 9,126.00 [23] costs were estimated
for the accelerated physiotherapy and in-patient rehabilita-
tion, respectively. The incremental cost-effectiveness ratio
estimate by Fusco etal. [22] and Krummenauer etal. [23]
was £1,538/QALY and −€841/QALY gained, respectively.
Overall, inpatient rehabilitation [23] was not cost-effective,
whereas accelerated physiotherapy was associated with cost
savings to the NHS of £200 per patient and additional 0.13
QALY [22].
Discussion
This is the first systematic review and meta-analysis on clini-
cal and cost-effectiveness of physiotherapy interventions fol-
lowing THR. The search strategy identified 20 clinical and
cost-effectiveness studies on physiotherapy interventions
from Australia, Brazil, USA, France, Italy, Germany, Ire-
land, Norway, Canada, Japan, Denmark, and United King-
dom. The risk of bias in these studies was assessed using the
Cochrane Risk of Bias Tool. All of the 18 studies included
for the clinical effectiveness of physiotherapy interventions
in the review had unclear or high risk of bias. The meth-
odological quality of the two cost-effectiveness studies was
assessed as adequate.
In line with the findings a systematic review by Lowe
etal. [13] on clinical effectiveness of physiotherapy exer-
cise following hip arthroplasty for osteoarthritis, the present
study confirmed that physiotherapy interventions improved
physical function, health-related quality of life, mobility,
and muscle strength. In addition, the findings of our review
showed that physiotherapy interventions improved self-per-
ceived function, postural stability, fast-walking speed, stair
climbing, and discharge destination following THR. On the
other hand, physiotherapy interventions did not reduce hos-
pital length of stay, fear of falling, hip pain, and function.
Furthermore, compared to out-patient physiotherapy inter-
ventions, inpatient physiotherapy interventions following
THR did not show a significantly superior cost-effectiveness
from a healthcare insurer perspective.
Table 3 Forest plot of the mean
difference I hip flexion for
total hip replacement between
physiotherapy and without
physiotherapy
Cot control, Tx treatment, CI confidence interval
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1396 Rheumatology International (2020) 40:1385–1398
1 3
The results of the meta-analysis of two studies [20, 31]
also showed that physiotherapy intervention was benefi-
cial compared to a control, which contradicts the findings
of Lowe and colleagues [13]. Their review which focussed
specifically on an outcome measure of range of motion such
as flexion, extension defect, and abduction that combined
data from four studies showed that there were no statistically
significant differences between groups for hip joint range of
motion. One possible reason for the contradiction may be
the characteristics of the physiotherapy interventions such
as exercise, duration of follow-up, and the outcome measures
used in the individual studies.
We have adopted a robust search strategy to locate and
identify all potential studies that investigated the effec-
tiveness and cost-effectiveness of physiotherapy interven-
tions including exercise, massage, taping, kinesiology,
rehabilitation, joint mobilisation, and sport. Four inde-
pendent reviewers have participated in the review process,
and it has been possible to include all relevant literature
in this study. Due to the fact that public health practition-
ers and policymakers are utilizing innovative and up-to-
date physiotherapy guidelines, this review has focused on
studies carried out in the last 2 decades. Given the small
number of studies included for this review, the clinical
and cost-effectiveness of physiotherapy interventions
should be interpreted with caution. The present review
may have been affected by language bias. Consequently,
a small number of studies published in languages other
than English might have been excluded and it is difficult
to generalize the clinical and cost-effectiveness of physi-
otherapy interventions based on the findings of this review.
Table 4 Summary of the characteristics of the studies reporting the clinical outcomes and cost-effectiveness for patients of THR
Int intervention, Cot control, WOMAC Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index
φ CHERS Quality score
Study/location/
study design/time-
horizon
Population Intervention Control Outcomes/meas-
urement used Cost/perspective Results (Int vs Cot) /24φ
Fusco etal.
[22]; UK/cost-
utility analy-
sis/12months
#80 Accelerated physi-
otherapy re-edu-
cation to increase
walking distance
and direction and
reduce reliance
on aids
Standard physi-
otherapy EuroQol EQ-5D Direct cost/
National Health
Service
Cost
I n = £504 per
patient
Cot = £705 per
patient
Effectiveness
Int = 0.91 (0.03)
Cot = 0.73 (0.05)
Cost-effectiveness
Int. was cost-effec-
tive than Cot
22
Krummenauer
etal. [23]
Germany/cost-
effectiveness
analysis/6months
#28 In-patient physi-
otherapy Out-patient physi-
otherapy WOMAC score
(%), utility, qual-
ity adjusted life
years
Direct costs/health-
care insurer Cost
Int = €9126.00;
Cot = €8706.00
Effectiveness
Int = 38% before,
and 87% after
surgery (WOMC
score)
Cot = 41% before,
and 88% after
surgery
Cost-effectiveness
Cost/effect = €420
[198, 475]/0.77
[95% CI − 2.13,
3.18] QALYs
= −€841/QALY
(p = 0.791)
Inpatient reha-
bilitation was
not cost-effective
compared to out-
patient rehabilita-
tion
20
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1397Rheumatology International (2020) 40:1385–1398
1 3
Conclusion
This review indicates that following THR, patients with
OA of the hip showed significant improvement in physical
function, health-related quality of life, mobility, and muscle
strength with physiotherapy interventions in a short term. On
the other hand, physiotherapy interventions were not effec-
tive in terms of hospital length of stay, acute length of stay,
fear of falling, and hip pain and function for patients follow-
ing THR. In relation to the findings of the cost-effectiveness
of physiotherapy interventions in this review, it is difficult to
reach a conclusion as they were based on a small number of
studies. In addition, outcome measures used in future studies
need to include those which measure (or reflect) the wider
social determinants of health; for example, the perspectives
of patients, their caregivers, and other societal perspectives.
Author contributions FF, JMW, GY, and TG had conceived, designed,
analysed the data, and interpreted the results of the work. FF, JMW,
GY, and TG wrote and critically revised the paper. All authors approved
the final version of this manuscript.
Funding This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Compliance with ethical standards
Conflict of interest None of the authors have any competing interests
to declare.
Ethical approval The study is a systematic review. For this study, ethi-
cal approval was not required.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/.
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