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Supervised versus unsupervised rehabilitation following total knee arthroplasty: A systematic review and meta-analysis

  • Author Footnotes
    1 These authors share same authorship based on equal contribution to this work.
    Marco Bravi
    Footnotes
    1 These authors share same authorship based on equal contribution to this work.
    Affiliations
    Department of Physical and Rehabilitation Medicine, Campus Bio-Medico University, Rome, Italy
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  • Umile Giuseppe Longo
    Correspondence
    Corresponding author at: Via Alvaro Del Portillo 5, Rome 00128, Italy.
    Affiliations
    Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy

    Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
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  • Andrea Laurito
    Affiliations
    Department of Physical and Rehabilitation Medicine, Campus Bio-Medico University, Rome, Italy
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  • Alessandra Greco
    Affiliations
    Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy

    Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
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  • Martina Marino
    Affiliations
    Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy

    Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
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  • Mirella Maselli
    Affiliations
    Department of Physical and Rehabilitation Medicine, Campus Bio-Medico University, Rome, Italy
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  • Silvia Sterzi
    Affiliations
    Department of Physical and Rehabilitation Medicine, Campus Bio-Medico University, Rome, Italy
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  • Author Footnotes
    1 These authors share same authorship based on equal contribution to this work.
    Fabio Santacaterina
    Footnotes
    1 These authors share same authorship based on equal contribution to this work.
    Affiliations
    Department of Physical and Rehabilitation Medicine, Campus Bio-Medico University, Rome, Italy
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  • Author Footnotes
    1 These authors share same authorship based on equal contribution to this work.
Published:November 18, 2022DOI:https://doi.org/10.1016/j.knee.2022.11.013

      Abstract

      Background

      Outcomes after total knee arthroplasty (TKA) are strongly influenced by the adequacy of rehabilitation and the consequent functional recovery. The economic impact of rehabilitation it is not negligible. Inpatient rehabilitation can be 5 to 26 times more expensive than the home-based rehabilitation. This topic is extremely relevant as the COVID-19 pandemic has highlighted the importance of unsupervised rehabilitation in orthopedic surgery. The aim of this review and meta-analysis is to investigate the scientific evidence regarding the comparison between supervised and unsupervised rehabilitation following TKA.

      Materials and Methods

      Following PRISMA guideline, a comprehensive search of PubMed, Cochrane and Scopus databases using combinations of keywords and MeSH descriptors: “total “Knee replacement,” “Arthroplasty”, “Rehabilitation” was performed from inception to December 2021. All relevant articles were retrieved, and their bibliographies were searched for further relevant references. Only English written randomized controlled trials comparing supervised and unsupervised rehabilitation following TKA were included in this systematic review. The outcomes considered were long-term pain, physical function, knee flexion and extension ROM, 6 minute walking test (6MWT) and timed up and go test (TUG).

      Results

      11 studies (2.181 patients in total) were included in this systematic review.
      The long-term pain outcome showed no significant differences (Std. Mean Difference [SMD] = 0.00, 95 % confidence interval [CI] −0.16, 0.017) between the supervised (n = 397) and unsupervised (n = 255). Physical function showed no significant differences among the two groups (mean difference [MD] = 0.84, 95 % CI = -1.82, 3.50). Non-significant differences were also found for knee ROM flexion (mean difference [MD] = -0.46, 95 % CI = -2.95, 2.04) and for knee extension (mean difference [MD] = 0.54, 95 % CI = -0.89, 1.97). At the 52-week follow-up, the unsupervised group showed significant better results in 6MWT (mean difference [MD] = -26.10, 95 % CI = -47.62, −4.59) and in Timed up and go test (mean difference [MD] = 1.33, 95 % CI = 0.50, 2.15).

      Conclusion

      This systematic review did not show a significant clinical difference in improving pain, function, and mobility outcomes after TKA between supervised PT and unsupervised PT. Therefore, it would appear that supervised rehabilitation did not had additional benefits compared to unsupervised rehabilitation.

      Keywords

      1. Introduction

      In Italy, more than half of people over the age of 65 suffers from a degenerative disease. The most frequent is osteoarthritis, which affects the osteoarticular system causing a high risk of motor disability. [
      • Longo U.G.
      • Silva S.
      • Perdisa F.
      • Salvatore G.
      • Filardo G.
      • Berton A.
      • et al.
      Gender related results in total knee arthroplasty: a 15-year evaluation of the Italian population.
      ] Total knee arthroplasty (TKA) is the definitive treatment for patients suffering from severe osteoarthritis [
      • Kurtz S.M.
      • Ong K.L.
      • Schmier J.
      • Mowat F.
      • Saleh K.
      • Dybvik E.
      • et al.
      Future clinical and economic impact of revision total hip and knee arthroplasty.
      ,
      • Bade M.J.
      • Kohrt W.M.
      • Stevens-Lapsley J.E.
      Outcomes before and after total knee arthroplasty compared to healthy adults.
      ], and the success of this procedure depends on the surgical techniques and the longevity of the implant: two elements that have been improving significantly in recent years [
      • Barrack R.L.
      • Ruh E.L.
      • Chen J.
      • Lombardi A.V.
      • Berend K.R.
      • Parvizi J.
      • et al.
      Impact of socioeconomic factors on outcome of total knee arthroplasty.
      ,
      • Ibrahim M.S.
      • Alazzawi S.
      • Nizam I.
      • Haddad F.S.
      An evidence-based review of enhanced recovery interventions in knee replacement surgery.
      ]. Population aging and increasing obesity contribute to a higher prevalence of osteoarthritis and a greater need for TKA [
      • Deshpande B.R.
      • Katz J.N.
      • Solomon D.H.
      • Yelin E.H.
      • Hunter D.J.
      • Messier S.P.
      • et al.
      Number of Persons With Symptomatic Knee Osteoarthritis in the US: Impact of Race and Ethnicity, Age, Sex, and Obesity.
      ]. In the United States, the incidence of TKAs increased from 145.4 to 223.0 per 100,000 people, in the first decade of the 2000 s. It is estimated that the total number of TKAs performed in the United States is increased from 711,000 in 2011 to 3.48 million by 2030, and overall total knee revisions are projected to grow by 601 % between 2005 and 2030 [
      • Kurtz S.
      • Ong K.
      • Lau E.
      • Mowat F.
      • Halpern M.
      Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.
      ]; between the years 2001 and 2016, a total of 848,863 TKAs have been performed in Italy. TKAs in women showed an increase of 138 %, and of 256 % in men [
      • Longo U.G.
      • Silva S.
      • Perdisa F.
      • Salvatore G.
      • Filardo G.
      • Berton A.
      • et al.
      Gender related results in total knee arthroplasty: a 15-year evaluation of the Italian population.
      ].
      Despite the improvements in surgical techniques, the outcomes after TKA remain strongly influenced by the adequacy of rehabilitation and the consequent functional recovery [
      • Mistry J.
      • Elmallah R.
      • Bhave A.
      • Chughtai M.
      • Cherian J.
      • McGinn T.
      • et al.
      Rehabilitative Guidelines after Total Knee Arthroplasty: A Review.
      ]. The increase in TKA procedures translates into a significant increase in health care cost; in fact, in addition to the cost of the surgery itself, the long period of post-surgical rehabilitation significantly increases the costs of assistance. The different economic impacts of the type of rehabilitation path undertaken after TKA has already been described in the literature [
      • Lavernia C.J.
      • D’Apuzzo M.R.
      • Hernandez V.H.
      • Lee D.J.
      • Rossi M.D.
      Postdischarge Costs in Arthroplasty Surgery.
      ,
      • Tribe K.L.
      • Lapsley H.M.
      • Cross M.J.
      • Courtenay B.G.
      • Brooks P.M.
      • March L.M.
      Selection of patients for inpatient rehabilitation or direct home discharge following total joint replacement surgery: A comparison of health status and out-of-pocket expenditure of patients undergoing hip and knee arthroplasty for osteoarthritis.
      ,
      • Naylor J.M.
      • Hart A.
      • Mittal R.
      • Harris I.
      • Xuan W.
      The value of inpatient rehabilitation after uncomplicated knee arthroplasty: A propensity score analysis.
      ]: inpatient rehabilitation can be 5 to 26 times more expensive than the home-based rehabilitation, showing no differences between the final results.
      Previous systematic reviews of randomized controlled trials (RCT) [
      • Buhagiar M.A.
      • Naylor J.M.
      • Harris I.A.
      • Xuan W.
      • Adie S.
      • Lewin A.
      Assessment of Outcomes of Inpatient or Clinic-Based vs Home-Based Rehabilitation After Total Knee Arthroplasty: A Systematic Review and Meta-analysis.
      ,
      • Minns Lowe C.J.
      • Barker K.L.
      • Dewey M.
      • Sackley C.M.
      Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials.
      ,
      • Artz N.
      • Elvers K.T.
      • Lowe C.M.
      • Sackley C.
      • Jepson P.
      • Beswick A.D.
      Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis.
      ] have focused on the type of rehabilitation setting (inpatient or outpatient/home based) and concluded that it does not significantly influence recovery after TKA; however, differences between supervised and unsupervised rehabilitation have not been studied. Several RCTs[
      • Xu T.
      • Yang D.
      • Liu K.
      • Gao Q.
      • Lu H.
      • Qiao Y.
      • et al.
      Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study.
      ,
      • Crawford D.A.
      • Duwelius P.J.
      • Sneller M.A.
      • Morris M.J.
      • Hurst J.M.
      • Berend K.R.
      • et al.
      2021 Mark Coventry Award: Use of a smartphone-based care platform after primary partial and total knee arthroplasty: a prospective randomized controlled trial.
      ,
      • Prvu Bettger J.
      • Green C.L.
      • Holmes D.N.
      • Chokshi A.
      • Mather R.C.
      • Hoch B.T.
      • et al.
      Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty.
      ,
      • Fleischman A.N.
      • Crizer M.P.
      • Tarabichi M.
      • Smith S.
      • Rothman R.H.
      • Lonner J.H.
      • et al.
      2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial.
      ], including multicentre prospective randomized controlled trials [
      • Crawford D.A.
      • Duwelius P.J.
      • Sneller M.A.
      • Morris M.J.
      • Hurst J.M.
      • Berend K.R.
      • et al.
      2021 Mark Coventry Award: Use of a smartphone-based care platform after primary partial and total knee arthroplasty: a prospective randomized controlled trial.
      ] utilizing large samples were published after the aforementioned reviews. Furthermore, this topic is extremely relevant as the COVID-19 pandemic has highlighted the importance of unsupervised rehabilitation in orthopedic surgery [
      • Azhari A.
      • Parsa A.
      Covid-19 Outbreak Highlights: Importance of Home-Based Rehabilitation in Orthopedic Surgery.
      ].
      This systematic review and meta-analysis investigates the scientific evidence regarding the comparison between supervised and unsupervised rehabilitation following TKA, with the aim of establishing whether unsupervised treatment can be a valid alternative due to the reduction of healthcare costs and improvement of rehabilitation outcomes.
      The hypothesis of this review is that some outcomes can be positively influenced by the supervised rehabilitation modality.

      2. Materials and methods

      2.1 Systematic literature search

      An online systematic search on the US National Library of Medicine (PubMed/MEDLINE), SCOPUS and the Cochrane Database of Systematic Reviews, was performed with no data limit until December 2021, according to The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines [

      Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021;372. https://doi.org/10.1136/bmj.n71.

      ] (Figure 1). To conduct an evidence-based practice literature search, the Population Intervention Comparison and Outcome (PICO) model was adopted [
      • Brown D.
      A Review of the PubMed PICO Tool: Using Evidence-Based Practice in Health Education.
      ] (Table 1).
      Figure thumbnail gr1
      Figure 1Selection flow diagram according to the PRISMA 2020 statement. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.or.
      Table 1PICO model.
      PopulationInterventionComparisonOutcome
      Adults with total knee replacementSupervised rehabilitationUnsupervised rehabilitationMobility (6MWT, TUG)Patient-reported outcomes

      (pain, function)Range of Motion

      (knee extension and knee flexion)
      The search strategy is reported in Table 2: it was used a combination of medical subject heading (MeSH) terms and free-text terms adjusted according to each database specification, furthermore an additional manual search and a reference lists examination was performed.
      Table 2Search strategy.
      DatabaseSearch terms
      PubMedTITLE-ABS (“total knee replacement*”) OR (“total knee arthroplasty*”) AND (rehab*) AND NOT (hip)
      SCOPUSTITLE-ABS (“total knee replacement*”) OR (“total knee arthroplasty*”) AND (rehab*) AND NOT (hip)
      Cochrane#1 MeSH descriptor: [Arthroplasty, Replacement, Knee] explode all trees]

      #2 MeSH descriptor: [Rehabilitation] explode all trees

      #3 #1 AND #2

      2.2 Eligibility criteria and data extraction

      In this systematic review and meta-analysis, the articles that fulfilled the following inclusion criteria were included: 1) English language full-text articles; 2) randomized clinical trials; 3) population of adults (age ≥ 18 years) that underwent TKA; 4) start of rehabilitation within 3 months of surgery; 4) comparison between supervised and unsupervised rehabilitation. We considered supervised rehabilitation as all the protocols involving rehabilitation supervised by physiotherapists, as there is no evidence of superiority of 1-to-1 treatment over group-based treatment [
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ], thus both treatment modalities were included. We excluded non-clinical studies, abstracts, editorials, review articles, book chapters, case reports, and all articles that did not compare supervised and unsupervised rehabilitation following TKA.
      Regarding the unsupervised rehabilitation, we included all studies in which patients underwent rehabilitation sessions performed via web-based platforms, exercise booklets, etc. without the supervision of a physiotherapist. We also considered those protocols that included periodic follow-ups to check progress and modify the rehabilitation plan as unsupervised.
      To be included, articles had to assess at least one of the following outcomes: 6-minute walk test (6MWT)[
      • Ko V.
      • Naylor J.M.
      • Harris I.A.
      • Crosbie J.
      • Yeo A.E.T.
      The six-minute walk test is an excellent predictor of functional ambulation after total knee arthroplasty.
      ] measured as meters walked on a flat surface in 6 minutes, timed up and go (TUG) test[
      • Givens D.L.
      • Eskildsen S.
      • Taylor K.E.
      • Faldowski R.A.
      • Del Gaizo D.J.
      Timed Up and Go test is predictive of Patient-Reported Outcomes Measurement Information System physical function in patients awaiting total knee arthroplasty.
      ] to measure physical performance, patient-reported pain and function measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)[
      • McConnell S.
      • Kolopack P.
      • Davis A.M.
      The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a review of its utility and measurement properties.
      ], Visual Analogical Scale (VAS), Knee Injury and Osteoarthritis Outcome Score (KOOS)[
      • Roos E.M.
      • Lohmander L.S.
      The Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis.
      ], and Range of Motion (ROM) in knee flexion and extension.
      Firstly duplicated references were checked and excluded through the Rayyan web app for systematic reviews [
      • Ouzzani M.
      • Hammady H.
      • Fedorowicz Z.
      • Elmagarmid A.
      Rayyan-a web and mobile app for systematic reviews.
      ]. Two reviewers (MB, FS) independently screened title and abstracts to identify eligible articles, then the two reviewers met to discuss the inclusion of all articles that were independently selected. At the end of this phase, the full text of the selected articles was screened by both reviewers to verify if they met eligibility criteria.
      After the selection of eligible studies, data was extracted, including the name of the first author, year of publication, study design and aim, characteristics of the participants (e.g., mean age, gender distribution, etc.), rehabilitation protocol, and summary of results. Any discrepancies that occurred in any of the phases described were discussed with a third reviewer (AL). For continuous variables we extracted means (SDs), according to the Cochrane Handbook for Systematic Reviews of Interventions version 6.2 [

      Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.2 (updated February 2021) 2021. www.training.cochrane.org/handbook. (accessed November 26, 2021).

      ] when the outcome was reported as a median value, interquartile ranges and mean value, and 95 % Cis, a conversion was computed. Regarding studies with incomplete data or with not directly detectable data, we initially tried to contact the corresponding author for feedback. In case of non-response or inability to provide additional data, we checked other reviews to verify the presence of the data of interest published in other systematic reviews.

      2.3 Quality assessment, risk of bias and evidence synthesis

      Two independent reviewers (MB, FS) assessed the methodological quality of included studies, a third reviewer (AL) was consulted if discrepancies were not resolved by discussion. According to Ma et al. [
      • Ma L.L.
      • Wang Y.Y.
      • Yang Z.H.
      • Huang D.
      • Weng H.
      • Zeng X.T.
      Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: What are they and which is better?.
      ] the Cochrane risk-of-bias tool for randomized trials was chosen for the methodological quality assessment of the included studies.
      The GRADE approach was used to assess the quality and strength of the evidence as high, moderate, low, and very low regarding main outcome (pain, function and mobility). Summary of findings tables were generated through the GRADEpro software.

      2.4 Statistical analysis

      Effect estimates of continuous data were calculated as mean difference (MD) or standardized mean difference (SMD) depending on the measurement scales used in the studies. MD was used when the included studies reported the result using the same units (e.g., KOOS), while SMD were chosen for continuous outcomes with different units, according to section 10.5.1 of Cochrane Handbook for Systematic Reviews [

      Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.2 (updated February 2021) 2021. www.training.cochrane.org/handbook. (accessed November 26, 2021).

      ]. We used Review Manager computer program (version 5.3) to perform statistical analyses. Results from studies with multiple intervention arms were treated in accordance with the method described by Higgins and Green [

      Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.2 (updated February 2021) 2021. www.training.cochrane.org/handbook. (accessed November 26, 2021).

      ] in section “16.5.4 How to include multiple groups from one study” of the Cochrane Handbook: each arm was separately compared with the shared intervention group divided evenly among the comparisons.
      The I2 statistic evaluates the proportion of variation (i.e., consistency) in the combined estimates due to the variance between studies. We pooled data using random-effect models when great heterogeneity assessed through the I2 statistics (value greater than 50 % was considered indicative of great heterogeneity) was found. The fixed effect models were used for I2 values below 50 % [

      Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.2 (updated February 2021) 2021. www.training.cochrane.org/handbook. (accessed November 26, 2021).

      ].

      3. Results

      A total of 3296 records were found, including 1162 from PubMed, 1810 from SCOPUS and 325 from Cochrane. After removing the duplicates, suitable articles were identified by reading the title and abstract. The full-text screening of the selected articles verified if they met the inclusion criteria and excluded the presence of any exclusion criteria. A total of 11 articles [
      • Xu T.
      • Yang D.
      • Liu K.
      • Gao Q.
      • Lu H.
      • Qiao Y.
      • et al.
      Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study.
      ,
      • Crawford D.A.
      • Duwelius P.J.
      • Sneller M.A.
      • Morris M.J.
      • Hurst J.M.
      • Berend K.R.
      • et al.
      2021 Mark Coventry Award: Use of a smartphone-based care platform after primary partial and total knee arthroplasty: a prospective randomized controlled trial.
      ,
      • Prvu Bettger J.
      • Green C.L.
      • Holmes D.N.
      • Chokshi A.
      • Mather R.C.
      • Hoch B.T.
      • et al.
      Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty.
      ,
      • Fleischman A.N.
      • Crizer M.P.
      • Tarabichi M.
      • Smith S.
      • Rothman R.H.
      • Lonner J.H.
      • et al.
      2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial.
      ,
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ,
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ,
      • Bini S.
      • Mahajan J.
      Clinical outcomes of remote asynchronous telerehabilitation are equivalent to traditional therapy following total knee arthroplasty: A randomized control study.
      ,
      • Kramer J.F.
      • Speechley M.
      • Bourne R.
      • Rorabeck C.
      • Vaz M.
      Comparison of Clinic- and Home-Based Rehabilitation Programs After Total Knee Arthroplasty.
      ,
      • Han A.S.Y.
      • Nairn L.
      • Harmer A.R.
      • Crosbie J.
      • March L.
      • Parker D.
      • et al.
      Early Rehabilitation After Total Knee Replacement Surgery: A Multicenter, Noninferiority, Randomized Clinical Trial Comparing a Home Exercise Program With Usual Outpatient Care.
      ,
      • Naylor J.M.
      • Crosbie J.
      • Ko V.
      Is there a role for rehabilitation streaming following total knee arthroplasty? Preliminary insights from a randomized controlled trial.
      ,
      • Büker N.
      • Akkaya S.
      • Akkaya N.
      • Gökalp O.
      • Kavlak E.
      • Ök N.
      • et al.
      Comparison of Effects of Supervised Physiotherapy and a Standardized Home Program on Functional Status in Patients with Total Knee Arthroplasty: A Prospective Study.
      ] were included in systematic review, of which 10 [
      • Xu T.
      • Yang D.
      • Liu K.
      • Gao Q.
      • Lu H.
      • Qiao Y.
      • et al.
      Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study.
      ,
      • Crawford D.A.
      • Duwelius P.J.
      • Sneller M.A.
      • Morris M.J.
      • Hurst J.M.
      • Berend K.R.
      • et al.
      2021 Mark Coventry Award: Use of a smartphone-based care platform after primary partial and total knee arthroplasty: a prospective randomized controlled trial.
      ,
      • Prvu Bettger J.
      • Green C.L.
      • Holmes D.N.
      • Chokshi A.
      • Mather R.C.
      • Hoch B.T.
      • et al.
      Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty.
      ,
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ,
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ,
      • Bini S.
      • Mahajan J.
      Clinical outcomes of remote asynchronous telerehabilitation are equivalent to traditional therapy following total knee arthroplasty: A randomized control study.
      ,
      • Kramer J.F.
      • Speechley M.
      • Bourne R.
      • Rorabeck C.
      • Vaz M.
      Comparison of Clinic- and Home-Based Rehabilitation Programs After Total Knee Arthroplasty.
      ,
      • Han A.S.Y.
      • Nairn L.
      • Harmer A.R.
      • Crosbie J.
      • March L.
      • Parker D.
      • et al.
      Early Rehabilitation After Total Knee Replacement Surgery: A Multicenter, Noninferiority, Randomized Clinical Trial Comparing a Home Exercise Program With Usual Outpatient Care.
      ,
      • Naylor J.M.
      • Crosbie J.
      • Ko V.
      Is there a role for rehabilitation streaming following total knee arthroplasty? Preliminary insights from a randomized controlled trial.
      ,
      • Büker N.
      • Akkaya S.
      • Akkaya N.
      • Gökalp O.
      • Kavlak E.
      • Ök N.
      • et al.
      Comparison of Effects of Supervised Physiotherapy and a Standardized Home Program on Functional Status in Patients with Total Knee Arthroplasty: A Prospective Study.
      ] included in the meta-analysis (Figure 1). The study [
      • Fleischman A.N.
      • Crizer M.P.
      • Tarabichi M.
      • Smith S.
      • Rothman R.H.
      • Lonner J.H.
      • et al.
      2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial.
      ] was excluded due to the impossibility of finding the data in the form necessary for the execution of the meta-analysis.After the selection of the admissible studies, the data was extracted, as described above in section 2.2 Eligibility criteria and data extraction and reported in Table 3.
      Table 3Details of included studies.
      Author (year)Design and AimParticipantsRehabilitation protocolOutcomes and follow-upResults
      Bini et al. (2017)RCT



      To compare physical therapy delivered through an asynchronous video-based tool to traditional in-person outpatient PT following routine TKA.
      28 patients with TKA (design of implant and name of commercial product not reported)

      Super group

      (n = 15)

      - Mean age: 63.6

      - Gender; 9 M / 6F

      Unsuper group

      (n = 13)

      -Age: 62.9

      - Gender: 6 M / 7F

      Both group followed a pre-operative education class and a single posto-operative care protocol



      Super group:

      Conventional outpatient rehabilitation



      Unsuper group:

      Home program using an application with remote video on mobile (asynchronous). A therapist remotely monitors progress and changes the schedule (not in real time)
      FU: 3-month post-surgery (24 weeks)



      OUTCOME:- VAS

      (Visual Analogue Scale)



      - KOOS -PS



      - Veterans-RAND Physical Component Score

      (VR-12 PCS)

      - Veterans-RAND Mental Component Score

      (VR-12 MCS)


      Clinical outcomes following asynchronous telerehabilitation administered over the web and through a hand-held device were not inferior to those achieved with traditional care.
      Büker et al. (2014)RCT



      To determine the functional differences between TKA patients who were treated with supervised physiotherapy or a standardized home program and perform a cost analysis
      34 patients with TKA (ligament-preserving TKA, name of commercial product not reported)

      Super group

      (n = 18)

      - Mean age: 64,25 ± 3,86

      - Gender: 2 M/16F

      - BMI: 35,44 ± 7,6

      Unsuper group

      (n = 16)

      - Mean age: 64,08 ± 6,25

      - Gender: 1 M/15F

      - BMI: 28,81 ± 5,37
      Super group: patients in supervised physiotherapy participated in a total of 20 sessions of a physiotherapy and rehabilitation program 5 days a week for 4 weeks. The program included: knee joint ROM exercises, strengthening exercises for the knee and hip,

      20 min of application of moist heat, and 20 min of conventional transcutaneal electrical nerve stimulation (TENS) application.



      Unsuper group: patients performed home exercise for an hour a day, 5 days a week, for 4 weeks. Home exercises included

      arrangement of knee joint motion limit, restoration of knee and hip muscle power.
      FU: at 3, 6, 12, 24 months post-operatively



      OUCOME:

      -VAS



      -Beck Depression Scale



      -Knee flexion and extension ROM



      -WOMAC



      -SF-36


      No difference between the patients performing supervised or unsupervised with respect to the effects on functional status. A home exercise program can be used patients with TKA, which can also reduce health-care spending.
      Correia et al (2018)RCT



      To compare the clinical outcomesof a home-based program using a novel digital biofeedback system for home-based physical rehabilitation (SWORD)

      against conventional in-person home-based rehabilitation after TKA.
      Fifty-nine patients with TKA (design of implant and name of commercial product not reported)



      Super group

      (n = 29)

      - Age: 70 ± 7.2

      - Gender: 71 % F / 29 % M

      - BMI: 30.8 ± 5.4

      Unsuper group

      (n = 30)

      - Age: 67.3 ± 6.8

      - Gender: 84.2 % F / 15.8 % M

      - BMI: 31 ± 4.5
      Super group:

      Conventional rehabilitation group, each patient had 24 face-to-face sessions consisting in soft tissue massages, active assisted mobilization, open kinetic chain (OKC) exercise, gait training, strengthening exercises and ice pack application for the first 2 weeks; 3 to 6 weeks closed kinetic chain (CKC) exercises and gait training without external support were added; 7–8 weeks eccentric and weight bearing exercises including steps exercise were added.



      Unsuper group:

      Unsupervised rehabilitation program was carried out with the use of a digital biofeedback system for home-based physical rehabilitation and remote monitoring. Each patient had 3 face-to-face contacts with the therapist (on deployment, 4 weeks into the rehabilitation program and on termination). The rehabilitation program consisted in OKC exercise, strengthening exercises and ice pack application for the first 2 weeks; 3 to 6 weeks exercise with steps, CKC exercise, standing exercise without support; 7–8 weeks, eccentric and multidirectional exercises were added.
      FU: 8 weeks post-surgery



      OUTCOME:-TUG

      (Time Up and Go)



      - Knee flexion and extension ROM



      -KOOS Pain


      The study demonstrated a superiority of the unsupervised group for all outcomes. Independent-home based rehabilitation after TKA with the digital biofeedback system is feasible, safe and effective.
      Crawford et al. (2021)RCT



      To determine the non-inferiority of a smartphone-based exercise educational care management system after primary knee arthroplasty compared with a traditional in-person

      physiotherapy rehabilitation model.
      345 patients with TKA (design of implant and name of commercial product not reported)



      Super group

      (n = 185)

      - Mean age: 64.5 ± 8.9

      - Gender: 75 M / 110F

      - Mean BMI: 31 ± 3 6.5

      - Unsuper group TKA

      (n = 160)

      - Mean age: 63.2 ± 8.6

      - Gender: 54 M / 106F

      - Mean BMI: 32.2 ± 6.4
      Super group: conventional outpatient rehabilitation sessions (3 times/week for 4 weeks).

      Unsuper group: application-based program using smartphone/smartwatch and MyMobility smartphone platform

      (3 times / day, 6 days / week for 6 weeks).
      FU: 1 month and 3 months post-surgery



      OUTCOME:

      -KOOS



      -TUG



      - Knee flexion ROM



      - EQ-5D-5L



      -Single Leg Stance


      The use of the unsupervised care platform demonstrated similar early outcomes to traditional care models, while requiring significantly less postoperative physiotherapy visits.
      Fleischmann et al. (2019)RCT



      To compare the efficacy of an unsupervised home exercise program, through an interactive web-based program or a printed paper manual, with the routine prescription of outpatient PT services after primary, unilateral TKA
      290 patients with TKA (cemented posterior stabilized or cruciate retaining TKA, name of commercial product not stated)

      Super group

      (n = 97)

      - Age: 65

      - Gender: 47M50F

      - BMI: 31

      Unsuper group

      (n = 193) was divided into:1) Web PT

      (n = 96)

      -Age: 65

      - Gender: 47 M / 49 / F

      - BMI: 312) paper PT

      (n = 97)

      -Age: 66

      - Gender: 48 M / 49F

      - BMI: 30
      Super group: outpatient PT group received formal outpatient PT supervised by a licensed therapist with two to three weekly sessions for 4 to 8 weeks after surgery.



      Unsuper group: the web PT and paper PT groups followed an 8-week unsupervised home exercise program using either an interactive web-based platform (FORCE Therapeutics, New York, NY, USA) or a printed PT manual that was provided to patients before discharge. Both unsupervised home-based PT programs recommended the same weekly exercises, which were to be performed three times daily and graduated from week to week.
      FU: 4–6 weeks and 6 months post-operatively.



      OUTCOME:

      - Knee flexion ROM



      - KOOS


      Unsupervised home exercise is an effective and adequate rehabilitation strategy for selected patients undergoing

      primary, unilateral TKA
      Han et al. (2015)RCT



      To determine whether the home exercise program (HEP) is not inferior to usual care in terms of self-reported pain and physical function, knee ROM, walking ability, and safety at 6 weeks.
      390 patients with TKA (cemented posterior stabilized or cruciate retaining TKA, name of commercial product not stated)

      Super group

      (n = 196)

      -Mean age: 65.4 ± 6.0

      -Gender: 92 M / 104F

      -BMI: 32.2 ± 6.3

      Unsuper group

      (n = 194)

      - Mean age: 64.1 ± 6.5

      - Gender: 88 M/ 106F

      - BMI: 32.2 ± 5.5
      Super group: postoperative rehabilitation

      recommended by hospital or orthopedic

      surgeon. Super group mostly involved access to clinic-based outpatient physiotherapy for the 6 weeks after discharge from the orthopedic ward.



      Unsuper group: the patients allocated to the HEP received 1 session of instruction from a physiotherapist prior to hospital discharge and received a written copy of the HEP and instructions regarding effective icing. Brief weekly telephone calls were made thereafter to monitor adherence and evaluate readiness to commence the intensive exercise. Rehabilitation protocol consisted in weeks 1–2: 6 exercises to increase full active and passive ROM in sitting and supine positions; weeks 3–6 focused on 6 functional and weight-bearing exercises to increase ROM and maintain muscle strength. Patients were asked to complete 10 repetitions of each exercise, 3 times daily
      FU: 6 weeks. Post-operatively



      OUTCOME:

      -WOMAC



      -Knee flexion and extension ROM



      −50-Foot Walk Time (50-FWT)


      Delivery of a monitored HEP is not inferior in terms of WOMAC pain and physical function, knee ROM, walking speed, to access to clinic-based usual care physiotherapy during the first 6 weeks after hospital discharge among patients with TKA.
      Ko et al. (2013)RCT



      To determine whether center-based, one-to-one physical therapy provides superior outcomes compared with group-based therapy or a simple monitored home-based program in terms of functional and physical recovery and health-related quality of life after TKA
      249 patients with TKA (cement fixation used for all participants; posterior stabilizing, cruciate retaining and additional patellar resurfacing were seurgeon-dependent. Name of commercial product not stated)

      Super group

      (n = 169)

      Divided into:1-to-1 Therapy

      (n = 85)

      -Mean age: 67 ± 9

      -Gender: 32 % M/ 68 % F

      -BMI: 33 ± 6

      Group-based Therapy (n = 84)

      -Mean age: 68 ± 9

      -Gender: 40 % M/ 60 % F

      -BMI: 34 ± 6

      Unsuper group

      (n = 80)

      -Mean age: 67 ± 8

      -Gender: 39 % M/ 61 % F

      -BMI: 32 ± 5
      Super group

      1-to-1: 12 physiotherapy sessions with a physiotherapist over a 6 weeks period.



      Group-based: 12 group sessions over a 6-week period.



      Unsuper group: Participants attended two individual sessions at one of the participating physical therapy departments. At the first session, participants were instructed on the home-based exercise program and received an instructional DVD and a booklet with fortnightly exercise progressions.

      The second session occurred two weeks after: the therapist documented any adverse signs and symptoms and reviewed and modified the program as required.

      FU: 2 10, 26, 52 weeks post-operatively



      OUTCOME:

      -WOMAC Function



      -WOMAC Pain



      −6MWT

      -OKS

      (Oxford Knee Score)



      -Knee flexion and extension ROM






      One-to-one therapy does not provide superior self-reported or performance-based outcomes compared with group-based therapy or a home program, in the short term and the long term after TKA.
      Kramer et al. (2003)RCT



      To compare a

      clinic-based rehabilitation program

      delivered in outpatient physical therapy

      clinics against home-based rehabilitation monitored by a physical therapist via periodic telephone calls, on disease-specific, joint-specific, and functional outcome measures after TKA
      160 patients with TKA (Genesis - Smith

      and Nephew Orthopaedics, Memphis, TN; and AMK - DePuy, Warsaw, IN)

      Super group

      (n = 80)

      -Mean age: 68,2 ± 6,9

      -Gender: 33 M/47F

      Unsuper group

      (n = 80)

      -Mean age: 68,6 ± 7,8

      -Gender: 36 M/44F
      All patients received booklets, which included written and pictorial descriptions of each exercise and educational information on using ice, controlling swelling, walking, and ROM. They were instructed to complete the common home exercises 3 times daily until their 12-week follow-up.



      Super group:

      In addition to the common home exercises, patients in the clinic-based group were required to attend outpatient physical therapy between weeks 2 to 12 after surgery, for as many as two sessions per week, for 1 hour per session.



      Unsuper group:

      A physical therapist telephoned each patient in the home-based group at least once during Weeks 2 to 6 and once during Weeks 7 to 12 after surgery to ask whether the patient was having any problems with the exercises, to remind them of the importance of completing the exercises, and to provide advice on wound care, scar treatment, and pain control.
      FU: at 12 weeks and 52 weeks post-operatively



      OUTCOME:



      -WOMAC



      -KOOS Pain

      -Medical Outcomes Study Short Form – 36 (SF-36)

      ,



      −30-seconds Stair Test



      −6MWT



      -Knee Rating Scale



      -Knee Flexion ROM

      Prior to surgery there were no significant differences between groups (p > 0.01). Pain before surgery, as measured by the Knee Society clinical rating scale, was significantly greater than that at 12 and 52 weeks after surgery (p 0.01), while there was no statistically significant difference (p 0.01) between pain scores at 12 and 52 weeks.



      After primary total knee arthroplasty, patients who completed a standardized home exercise program performed similarly during the first 52 weeks after surgery, regardless of

      whether they participated in a clinic-based or a home-based rehabilitation program
      Naylor et al. (2015)RCT



      To determine whether patients who present with more mobility limitation at the commencement of rehabilitation after TKA, benefit more if they receive closer supervision during their rehabilitation
      233 patients with TKA (design of implant and name of commercial product not reported)

      Super group

      (n = 159)

      Divided into:1) One-to-one PT

      (n = 78)2) Group based PT

      (n = 81)

      Further divided according to the 6MWT into:a) Low performer (LP)

      (n = 89)

      - Mean age: 68.5 ± 8.2

      - Gender: 58 M / 31F

      - BMI: 33.8 ± 6.3b) High performer (HP)

      (n = 70)

      - Mean age: 65.8 ± 9.4

      - Gender: 43 M / 27F

      - BMI: 32.9 ± 5.8

      Unsuper group

      (n = 74)

      Further divided according to the 6MWT into:a) LP

      (n = 36)

      - Mean age: 65.7 ± 9.5

      - Gender: 23 M / 13F

      - BMI: 31.1 ± 5.8b) HP

      (n = 38)

      - Mean age: 67.5 ± 8.5

      - Gender: 23 M / 15F

      - BMI: 31.5 ± 4.4
      Super group:

      Distinct in “One-To-One” and “Group Based” Participants in the one-to-one or group-based programmes were prescribed an exercise-based home programme in addition to the supervised sessions to be conducted twice per week for 6 weeks. Exercise: brisk walking, exercise at parallel bars, stretching; Sit down and getting up from chair; step-ups using a step; knee flexion, stationary cycling, arm ergometry; stairs retraining; balance mat; marching; obstacle walking; upper and lower body movement exercises; general stretches including quadriceps, hamstring and calf stretches.



      Unsuper group:Patients in the unsupervised group were given the same home programme, to be conducted 4 times per week. Home programme participants were assessed twice by a physical therapist; at the beginning of formalized rehabilitation

      (2 weeks post-surgery) and at 4 weeks post-surgery. They were subsequently monitored via a telephone assessment at 6-weeks post-surgery. Exercise: brisk walking, sit down and getting up from chair, semi-squat without support, with weighted backpack (up to 5 kg), Step-ups using a step or bounded telephone books, support permitted with weighted backpack (up to 5 kg); calf raises; arm raises; standing knee flex, single leg standing, standing hip extension; shoulder range of motion in standing; walking, stationary cycling; quadriceps, hamstring and calf stretch.
      FU: at 10, 26 and 52 weeks post-operatively



      OUTCOME:

      −6MWT (% of the targeted prediction model)



      -WOMAC Function



      -WOMAC Pain
      Individuals manifesting comparatively poor mobility at the commencement of physiotherapy may recover their mobility, but not perceived function, more quickly if streamed to supervised therapy. Patients who, at entry to physiotherapy rehabilitation after TKA, is unable to walk more than 40 % of their 6MWT target, may benefit more through enrolment in a supervised exercise programme, while those who manage to achieve this target or better seem to be just as successful with a lower level of supervision.
      Prvu Bettger et al. (2020)RCT



      To examine costs and clinical noninferiority of a virtual PT program compared with traditional PT care after TKA.
      287 patients with TKA (design of implant and name of commercial product not reported)

      Super group

      (n = 144)

      -Mean age: 65,1 ± 9,2

      -Gender: 65,4% F

      -BMI: 31,9 ± 5,9

      Unsuper group

      (n = 143)

      -Mean age: 65,4 ± 7,7

      -Gender: 59,6% F

      -BMI: 31,6 ± 5,7
      Super group:

      Patients undergo traditional outpatient or home rehabilitation following their care team’s recommendations for all preoperative and postoperative medical and rehabilitative care.



      Unsuper group:Patients undergo rehabilitation using the Virtual Exercise Rehabilitation Assistant (VERA; Reflexion Health)

      . Patients had a video visit with their telehealth therapist in the week after hospital discharge and weekly to review progress and to revise the therapy regimen accordingly.
      FU: at 6 and 12 weeks post-operatively



      OUTCOME:

      -KOOS

      -Knee flexion and extension ROM

      (only at 6 weeks)



      Virtual PT with telerehabilitation for skilled clinical oversight significantly lowered 3-month health-care costs after TKA while providing similar effectiveness of traditional PT. Virtual PT with clinical oversight should be considered for patients managed with TKA.
      Xu et al. (2021)RCT



      To compare aself-developed, home-based, enhanced knee flexion exercise (KFEH)

      program, which involved the use of a low stool) and an exercycle, against standard supervised physiotherapy.
      106 patients with TKA (Posteriorcruciate stabilizing prostheses; name of commercial product not reported)

      Super group

      (n = 51)

      - Mean age: 67,3 ± 6,9

      - Gender: 8 M/43F

      - BMI: 21,5 ± 1,6



      Unsuper group (n = 55)

      - Mean age: 68,4 ± 8,4

      - Gender: 11 M/44F

      - BMI: 21,2 ± 2,5
      Super group: patients participated in a total of 24 sessions of a physiotherapy and rehabilitation program 2 days/week for the first 7 weeks, followed by 1 day/month for the remaining 10 months of the year. Exercises: knee joint ROM exercises andstrengthening exercises

      (including quadriceps setting exercise, straight leg raising exercise, stationary cycling, training strengthand length were individually designed)

      for the knee joint after 20 min of application of moist heat and 20 min of transcutaneous electrical nerve stimulation.





      Unsuper group: the program consisted of quadriceps femoris sets, hamstring sets, ankle pumps, terminal knee extension with weight, straight leg raises with weight in the supine and side-lying positions, cycling, and prone, hip, and knee flexion–extension with weight in supine, knee flexion–extension with weight in prone, and in sitting, static stretching exercises for hamstrings and gastrosoleus muscles, as well as a low stool-assisted knee joint bending exercise. Doctors in the team will guide patients through phone calls or WeChat to correct patient actions, answer patient questions once a week.
      FU: at 1 week and at 1, 3, 6 and 12 months post-operatively.



      OUTCOME:

      -VAS for pain



      -WOMAC Function



      -Knee flexion ROM



      -Knee Society Score


      The self-developed home-based enhanced knee flexion exercise program resulted in better ROM at early discharge. VAS, KSS, and WOMAC scores, and complication rates during the 12-month follow-up period were non-inferior to supervised PT. Has also been verified the efficiency and cost-effectiveness of using a home-based program for TKA rehabilitation.
      Abbreviation: RCT = Randomized Controlled Trial; PT = physical therapy; TKA = total knee arthroplasty; FU = follow up; EQ-5D-5L = 5-level EQ-5D version; SF-36 = Medical Outcomes Study Short Form – 36; WOMAC = Western Ontario and McMaster niversities Osteoarthritis Index; ROM = range of motion; KOOS = Knee Injury and Osteoarthritis Outcome Score; KOOS-PS = Knee injury and Osteoarthritis Outcome Score Physical Function Short Form VAS = Visual Analogical Scale.

      3.1 Characteristics and quality of included studies

      All included studies were RCTs with moderate to large sample sizes (smaller sample size = 28 patients [
      • Bini S.
      • Mahajan J.
      Clinical outcomes of remote asynchronous telerehabilitation are equivalent to traditional therapy following total knee arthroplasty: A randomized control study.
      ]; larger sample size = 390 patients [
      • Han A.S.Y.
      • Nairn L.
      • Harmer A.R.
      • Crosbie J.
      • March L.
      • Parker D.
      • et al.
      Early Rehabilitation After Total Knee Replacement Surgery: A Multicenter, Noninferiority, Randomized Clinical Trial Comparing a Home Exercise Program With Usual Outpatient Care.
      ]); in total 2.181 patients were included in this systematic review. The follow-ups ranged between 6 weeks and 52 weeks. A summary of the details of included studies is presented in Table 3.
      The methodological quality of the included studies was assessed using the Cochrane Risk of Bias tool (Review Manager RevMan [Computer program]. Version 5.3. The Cochrane Collaboration, 2020.). For randomized controlled trials (RCTs), the following items were rated: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete data outcome, selective reporting and other bias. Studies were rated as having a high, low, or unclear risk of bias for each component of the tool. (Figure 2A and Figure 2B). Specifically, almost all the studies obtained a low risk of bias in random sequence generation, blinding of outcome assessment, incomplete data outcome and selective reporting. The blinding of participants and personnel, due to the nature of the studies obtained a high risk of bias, while almost half of the studies obtained a high risk of bias for the allocation concealment.
      Figure thumbnail gr2
      Figure 2(A) Risk of bias summary: review authors’ judgements about each risk of bias item for each included study. (B) Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.

      3.2 Pain

      Eight of the 11 studies [
      • Xu T.
      • Yang D.
      • Liu K.
      • Gao Q.
      • Lu H.
      • Qiao Y.
      • et al.
      Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study.
      ,
      • Prvu Bettger J.
      • Green C.L.
      • Holmes D.N.
      • Chokshi A.
      • Mather R.C.
      • Hoch B.T.
      • et al.
      Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty.
      ,
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ,
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ,
      • Bini S.
      • Mahajan J.
      Clinical outcomes of remote asynchronous telerehabilitation are equivalent to traditional therapy following total knee arthroplasty: A randomized control study.
      ,
      • Han A.S.Y.
      • Nairn L.
      • Harmer A.R.
      • Crosbie J.
      • March L.
      • Parker D.
      • et al.
      Early Rehabilitation After Total Knee Replacement Surgery: A Multicenter, Noninferiority, Randomized Clinical Trial Comparing a Home Exercise Program With Usual Outpatient Care.
      ,
      • Naylor J.M.
      • Crosbie J.
      • Ko V.
      Is there a role for rehabilitation streaming following total knee arthroplasty? Preliminary insights from a randomized controlled trial.
      ,
      • Büker N.
      • Akkaya S.
      • Akkaya N.
      • Gökalp O.
      • Kavlak E.
      • Ök N.
      • et al.
      Comparison of Effects of Supervised Physiotherapy and a Standardized Home Program on Functional Status in Patients with Total Knee Arthroplasty: A Prospective Study.
      ] included in this systematic review were considered to carry out the meta-analysis on pain. These studies assessed pain using different evaluation scales: 2 studies used the KOOS Pain section [
      • Prvu Bettger J.
      • Green C.L.
      • Holmes D.N.
      • Chokshi A.
      • Mather R.C.
      • Hoch B.T.
      • et al.
      Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty.
      ,
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ], 3 studies used the VAS [
      • Xu T.
      • Yang D.
      • Liu K.
      • Gao Q.
      • Lu H.
      • Qiao Y.
      • et al.
      Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study.
      ,
      • Bini S.
      • Mahajan J.
      Clinical outcomes of remote asynchronous telerehabilitation are equivalent to traditional therapy following total knee arthroplasty: A randomized control study.
      ,
      • Büker N.
      • Akkaya S.
      • Akkaya N.
      • Gökalp O.
      • Kavlak E.
      • Ök N.
      • et al.
      Comparison of Effects of Supervised Physiotherapy and a Standardized Home Program on Functional Status in Patients with Total Knee Arthroplasty: A Prospective Study.
      ] and 3 studies used the WOMAC Pain section [
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ,
      • Han A.S.Y.
      • Nairn L.
      • Harmer A.R.
      • Crosbie J.
      • March L.
      • Parker D.
      • et al.
      Early Rehabilitation After Total Knee Replacement Surgery: A Multicenter, Noninferiority, Randomized Clinical Trial Comparing a Home Exercise Program With Usual Outpatient Care.
      ,
      • Naylor J.M.
      • Crosbie J.
      • Ko V.
      Is there a role for rehabilitation streaming following total knee arthroplasty? Preliminary insights from a randomized controlled trial.
      ]. Due to the heterogeneity in pain assessment modalities, the analysis of this result was performed using the SMD. Naylor et al [
      • Naylor J.M.
      • Crosbie J.
      • Ko V.
      Is there a role for rehabilitation streaming following total knee arthroplasty? Preliminary insights from a randomized controlled trial.
      ] included 3 intervention arms, two of which in the supervised group (1 to 1 supervised PT and group based supervised PT) reporting pooled results for the supervised group. However, in this study, the patients of each group were further divided into two sub-categories (“low performer” and “high performer” based on the results of the 6MWT), therefore, in the meta-analysis, we divided the study by treating the two categories of patients separately (Naylor 2015 A and Naylor 2015B). The study by Ko et al. [
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ] also had three study arms including two in the supervised group (1 to 1 supervised PT and group based supervised PT) in this case, given that the results were reported separately for the three groups, those obtained by the two supervised PT modalities were compared individually (Ko 2013a and Ko 2013b) with the results of the unsupervised group.
      The efficacy of supervised versus unsupervised PT regarding pain outcome was assessed at a short-term (6–12 weeks), at a mid-term (24–26 weeks) and at a long-term (52 weeks) FU. At the short-term FU, the total patients evaluated were 1.324, of which 748 in the supervised group and 576 in the unsupervised group; at mid-term FU 412 patients were included in the supervised group and 239 in the unsupervised group, while at the long-term FU the patients in the supervised group were 397 and 225 in the unsupervised group, for a total of 622 patients.
      I2 for heterogeneity ranged from 0 % at mid and long-term FU to 52 % at short-term. Most studies showed no differences between groups in pain outcome, with the exception of Correia et al. [
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ] that reported a significant improvement in pain outcome assessed with KOOS in the unsupervised group compared to the supervised group. The results of the meta-analysis show at the short-term FU a statistically significant difference in favor of the unsupervised group (Z = 2.30, p = 0.02), while non-significant differences were found at the mid-term (Z = 0.5; p = 0.45) and at the long-term FU (Z = 0.06, p = 0.95) between the two groups, (Figure 3A, 3B and 3C).
      Figure thumbnail gr3
      Figure 3Forest plot of the standardized mean difference in pain at 6–12 weeks (A), 24–26 weeks (B) and 52 weeks (C) follow-up after total knee arthroplasty between supervised and unsupervised physical therapy.
      The study by Kramer et al. [
      • Kramer J.F.
      • Speechley M.
      • Bourne R.
      • Rorabeck C.
      • Vaz M.
      Comparison of Clinic- and Home-Based Rehabilitation Programs After Total Knee Arthroplasty.
      ] was not included in the meta-analysis as it was not possible to retrieve the data, however the results described in the study are in agreement with the results of our meta-analysis in fact it reported a non-significant difference (p < 0.01) between the pain scores at 12 and 52 weeks, on the per-protocol and the intention-to-treat analysis between the supervised and unsupervised groups.

      3.3 Physical function

      Physical function was analyzed in 5 studies [
      • Xu T.
      • Yang D.
      • Liu K.
      • Gao Q.
      • Lu H.
      • Qiao Y.
      • et al.
      Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study.
      ,
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ,
      • Han A.S.Y.
      • Nairn L.
      • Harmer A.R.
      • Crosbie J.
      • March L.
      • Parker D.
      • et al.
      Early Rehabilitation After Total Knee Replacement Surgery: A Multicenter, Noninferiority, Randomized Clinical Trial Comparing a Home Exercise Program With Usual Outpatient Care.
      ,
      • Naylor J.M.
      • Crosbie J.
      • Ko V.
      Is there a role for rehabilitation streaming following total knee arthroplasty? Preliminary insights from a randomized controlled trial.
      ,
      • Büker N.
      • Akkaya S.
      • Akkaya N.
      • Gökalp O.
      • Kavlak E.
      • Ök N.
      • et al.
      Comparison of Effects of Supervised Physiotherapy and a Standardized Home Program on Functional Status in Patients with Total Knee Arthroplasty: A Prospective Study.
      ], all studies included in the meta-analysis used the WOMAC scale reporting the results of the physical function section separately. As for pain, the studies by Naylor et al. [
      • Naylor J.M.
      • Crosbie J.
      • Ko V.
      Is there a role for rehabilitation streaming following total knee arthroplasty? Preliminary insights from a randomized controlled trial.
      ] and by Ko et al. [
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ] has been split into two (Naylor 2015a and Naylor 2015b; Ko 2013a and Ko 2013b). Physical function was assessed at a short-term (6–12 weeks), at a mid-term (24–26 weeks) and at a long-term (52 weeks). I2 for heterogeneity ranged from 0 % at mid and long-term FU to 69 % at short-term FU.
      1.012 patients were included in the meta-analysis at a short-term FU, of which 593 in the supervised group and 419 in the unsupervised group. At mid and long-term FU 4 trials [
      • Xu T.
      • Yang D.
      • Liu K.
      • Gao Q.
      • Lu H.
      • Qiao Y.
      • et al.
      Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study.
      ,
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ,
      • Naylor J.M.
      • Crosbie J.
      • Ko V.
      Is there a role for rehabilitation streaming following total knee arthroplasty? Preliminary insights from a randomized controlled trial.
      ,
      • Büker N.
      • Akkaya S.
      • Akkaya N.
      • Gökalp O.
      • Kavlak E.
      • Ök N.
      • et al.
      Comparison of Effects of Supervised Physiotherapy and a Standardized Home Program on Functional Status in Patients with Total Knee Arthroplasty: A Prospective Study.
      ] reported data relating to physical function for a total of 622 patients (397 in the supervised group and 225 in the unsupervised group) in both Fus. Non-significant differences between the supervised and unsupervised PT were found (Z = 0.34, p = 0.74 at short-term; Z = 1.15; p = 0.25 at mid-term; Z = 0.62, p = 0.54 at long-term) (Figure 4A, 4B and 4C).
      Figure thumbnail gr4
      Figure 4Forest plot of the mean difference in WOMAC Physical Function at 6–12 weeks (A), 24–26 weeks (B) and 52 weeks (C) follow-up after total knee arthroplasty between supervised and unsupervised physical therapy.

      3.4 Knee range of motion

      The effect of the two intervention groups on the knee flexion and extension ROM was analyzed. I2 for heterogeneity ranged from 0 % at short and mid-term FU to 35 % at short-term FU.
      At short-term FU six studies [
      • Xu T.
      • Yang D.
      • Liu K.
      • Gao Q.
      • Lu H.
      • Qiao Y.
      • et al.
      Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study.
      ,
      • Crawford D.A.
      • Duwelius P.J.
      • Sneller M.A.
      • Morris M.J.
      • Hurst J.M.
      • Berend K.R.
      • et al.
      2021 Mark Coventry Award: Use of a smartphone-based care platform after primary partial and total knee arthroplasty: a prospective randomized controlled trial.
      ,
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ,
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ,
      • Han A.S.Y.
      • Nairn L.
      • Harmer A.R.
      • Crosbie J.
      • March L.
      • Parker D.
      • et al.
      Early Rehabilitation After Total Knee Replacement Surgery: A Multicenter, Noninferiority, Randomized Clinical Trial Comparing a Home Exercise Program With Usual Outpatient Care.
      ,
      • Büker N.
      • Akkaya S.
      • Akkaya N.
      • Gökalp O.
      • Kavlak E.
      • Ök N.
      • et al.
      Comparison of Effects of Supervised Physiotherapy and a Standardized Home Program on Functional Status in Patients with Total Knee Arthroplasty: A Prospective Study.
      ] for knee flexion were considered in meta-analysis for a total of 1.183 patients (648 patients in supervised group, and 535 patients in unsupervised group). Participants in the supervised group showed an average of 2.31° lower knee flexion (95 % CI −3.73, −0.89) than those in the unsupervised group (Figure 5A). At mid-term and long-term FU three studies [
      • Xu T.
      • Yang D.
      • Liu K.
      • Gao Q.
      • Lu H.
      • Qiao Y.
      • et al.
      Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study.
      ,
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ,
      • Büker N.
      • Akkaya S.
      • Akkaya N.
      • Gökalp O.
      • Kavlak E.
      • Ök N.
      • et al.
      Comparison of Effects of Supervised Physiotherapy and a Standardized Home Program on Functional Status in Patients with Total Knee Arthroplasty: A Prospective Study.
      ] were included with a total of 389 patients (238 in the supervised and 151 in the unsupervised group). At mid-term FU the results showed non-significant differences (Z = 0.57; p = 0.57) among the two groups (Figure 5B). Similar results were obtained at long-term FU with non-significant differences (Z = 0.36; p = 0.72) (Figure 5C). Fleischman et al. [
      • Fleischman A.N.
      • Crizer M.P.
      • Tarabichi M.
      • Smith S.
      • Rothman R.H.
      • Lonner J.H.
      • et al.
      2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial.
      ] reported that the difference in total change in knee flexion relative to the supervised group PT group was + 3° (95 % confidence interval [CI], −1° to 6°) for web unsupervised PT and + 5° (95 % CI, 1°-9°) for paper PT.
      Figure thumbnail gr5
      Figure 5Forest plot of the mean difference in knee flexion ROM at 6–12 weeks (A), 24–26 weeks (B) and 52 weeks (C) follow-up after total knee arthroplasty between supervised and unsupervised physical therapy.
      As for knee extension three studies [
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ,
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ,
      • Büker N.
      • Akkaya S.
      • Akkaya N.
      • Gökalp O.
      • Kavlak E.
      • Ök N.
      • et al.
      Comparison of Effects of Supervised Physiotherapy and a Standardized Home Program on Functional Status in Patients with Total Knee Arthroplasty: A Prospective Study.
      ] at short-term (8–12 weeks), and two studies [
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ,
      • Büker N.
      • Akkaya S.
      • Akkaya N.
      • Gökalp O.
      • Kavlak E.
      • Ök N.
      • et al.
      Comparison of Effects of Supervised Physiotherapy and a Standardized Home Program on Functional Status in Patients with Total Knee Arthroplasty: A Prospective Study.
      ] at mid and long-term FU were included. I2 for heterogeneity was 91 % at short-term, 58 % at mid-term and 0 % at long-term FU. At short-term FU Correia et al. [
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ] reported the change from baseline, while all the other studies reported the results at the FU, for this reason the SMD was used.
      At short-term FU results from 216 and 126 patients respectively in supervised and unsupervised group (total patients 342) reported non-significant differences (Z = 0.28; p = 0.78). Similarly, at mid and long-term FU (187 and 96 patients respectively in supervised and unsupervised group for a total of 283 patients) results showed non-significant differences among groups (at mid-term FU: Z = 0.44, p = 0.66; at long-term FU: Z = 0.74, p = 0.46) (Figure 6A, 6B and 6C).
      Figure thumbnail gr6
      Figure 6Forest plot of the standardized mean difference in knee extension ROM at 8–12 weeks (A) follow up. Forest plot of the mean in knee extension at 24–26 weeks (B) and 52 weeks (C) follow-up after total knee arthroplasty between supervised and unsupervised physical therapy.

      3.5 Mobility

      The 6MWT was used by two studies [
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ,
      • Kramer J.F.
      • Speechley M.
      • Bourne R.
      • Rorabeck C.
      • Vaz M.
      Comparison of Clinic- and Home-Based Rehabilitation Programs After Total Knee Arthroplasty.
      ] at short and long-term FU, only Ko et al. [
      • Ko V.
      • Naylor J.
      • Harris I.
      • Crosbie J.
      • Yeo A.
      • Mittal R.
      One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty.
      ] used 6MWT to assess mobility at long-term FU. At a short-term FU (10–12 weeks) participants in the supervised group (n = 234) walked on average −13.67 m (95 % CI [-35.61, 8.26]) compared to the unsupervised group (n = 142) (Figure 7A). At mid-term FU, participants in the supervised group (n = 169) walked on average 3.84 m (95 % CI [–22.81, 30.48]) compared to the unsupervised group (n = 80) (Figure 7B). At the long-term FU, significant differences were found: the supervised group showed a MD of −26.10 m (95 % CI [-47.62, −4.59]) compared to the unsupervised group (Figure 7C).
      Figure thumbnail gr7
      Figure 7Forest plot of the mean difference at short-term (10–12 weeks) (A), at mid-term (24–26 weeks) (B) and at long-term (52 weeks) follow-up (>12 months) of 6 Minutes Walking Test after total knee arthroplasty between supervised and unsupervised physical therapy.
      Two studies evaluated TUG test [
      • Crawford D.A.
      • Duwelius P.J.
      • Sneller M.A.
      • Morris M.J.
      • Hurst J.M.
      • Berend K.R.
      • et al.
      2021 Mark Coventry Award: Use of a smartphone-based care platform after primary partial and total knee arthroplasty: a prospective randomized controlled trial.
      ,
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ] performance at a single short-term follow-up (8–12 weeks). Significant difference was found, patients in the supervised group (n = 214) took an average of 1.33 s (95 % CI [0.50, 2.15]) longer than the unsupervised group (n = 190) (Figure 8).
      Figure thumbnail gr8
      Figure 8Forest plot of the mean difference at short-term follow-up (8–12 weeks) of Timed Up and Go test after total knee arthroplasty between supervised and unsupervised physical therapy.

      3.6 Evidence synthesis

      Based on the GRADE approach, at both short-term and mid-term FU low to moderate quality of evidence suggests little or no difference between supervised and unsupervised PT for pain, function, and mobility. At long-term FU similarly low to moderate quality of evidence with no difference was reported for pain and function; low-quality of evidence from a single study has been reported for the 6MWT indicating that the supervised group travels an average of 26.10 meters less than the unsupervised group (Table 4).
      Table 4Summary of findings.
      OutcomesNo. of participants (studies)Certainty of the Evidence (GRADE)Anticipated absolute effects (95 % CI)

      Mean value with Unsupervised PT
      MD With Supervised PT Rehabilitation (95 % CI)
      At short-term (6–12 weeks)
      Pain (WOMAC pain; VAS)1324

      (6 RCTs)
      ⊕⊕○○

      Lowa,b
      N.E.0.2 points (0.03 to 0.37 points)*
      Function (WOMAC function)1012

      (5 RCTs)
      ⊕⊕⊕○

      Moderatec
      The function ranged from 22.4 to 39.9 points0.88 points (-4.25 to 6 points)
      Mobility (6MWT)376

      (2 RCTs)
      ⊕⊕○○

      Lowe,f
      The 6MWT ranged from 340 to 386.5 meters−13.67 meters

      (-35.61 to 8.26 meters)
      At mid-term (24–26 weeks)
      Pain (WOMAC pain; VAS)651



      (5 RCTs)
      ⊕⊕○○

      Lowc,d
      N.E.−0.06 points (-0.22 to 0.1 points)*
      Function (WOMAC function)622

      (4 RCTs)
      ⊕⊕⊕○

      Moderatec
      The function ranged from 15.2 to 35.6 points−1.59 points (-4.31 to 1.13 points)
      Mobility (6MWT)249

      (1 RCT)
      ⊕⊕○○

      Lowe,g
      The mean 6MWT was 401.5 meters3.84 meters

      (–22.81 to 30.48 meters)
      At long-term (52 weeks)
      Pain (WOMAC pain; VAS)622



      (4 RCTs)
      ⊕⊕○○

      Lowc,d
      N.E.0 points (-0.16 to 0.17 points)*
      Function (WOMAC function)622

      (4 RCTs)
      ⊕⊕⊕○

      Moderatec
      The function ranged from 9.1 to 35.9 points0.84 points (-1.82 to 3.5 points)
      Mobility (6MWT)376

      (2 RCTs)
      ⊕⊕○○

      Lowe,f
      The 6MWT ranged from 400 to 425 meters−26.1 meters

      (-47.62 to −4.59 meters)
      GRADE Working Group grades of evidence.
      High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
      Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
      Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
      Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
      Abbreviation: GRADE = Grading of Recommendations, Assessment, Development and Evaluation; MD = mean difference; N.E. = not estimable; WOMAC = Western Ontario and McMaster University Osteoarthritis index; RCT = randomized clinical trial; 6MWT, 6-minute walk test.
      Explanations:
      a. No allocation concealment in more than 1 study and randomization according to geographical criteria in 1 study.
      b. Results were inconsistent across studies.
      c. No allocation concealment in more than 1 study.
      d. Unclear selective reporting bias in more than 1 studies.
      e. Total sample size was less than 400 patients.
      f. Higher loss to follow-up in unsupervised group (28%) against supervised group (19%) in 1 study.
      g. Only 1 study.
      *Standardized mean difference.

      4. Discussion

      The most important finding of the preset study was that supervised PT did not show superior outcomes compared to unsupervised PT for pain, function, ROM, and mobility after TKA. However, the results were obtained with low to moderate quality trials.
      A significant finding that emerged from this meta-analysis concerns the assessment of short-term pain with the clinical scales VAS, WOMAC Pain and KOOS Pain. In fact, the data shows a greater reduction of pain in the short term (6–12 weeks) in patients who have followed an unsupervised rehabilitation program. A possible explanation for this result could be that patients following an unsupervised exercise program tend to remain in their comfort zone in order to avoid painful symptoms. While, on the other hand, one of the main objectives of supervised physiotherapy is to offer the patient increasingly challenging exercises that lead them to leave their comfort zone. In fact, a recent study [
      • Rhim H.C.
      • Lee J.H.
      • Lee S.J.
      • Jeon J.S.
      • Kim G.
      • Lee K.Y.
      • et al.
      Supervised Rehabilitation May Lead to Better Outcome than Home-Based Rehabilitation Up to 1 Year after Anterior Cruciate Ligament Reconstruction.
      ] on a population that underwent anterior cruciate ligament (ACL) reconstruction shows that there is a significant difference in favor of the supervised group, since in the home-based group, the exercises were probably not carried out with the same commitment and selectivity of the supervised group which performed the exercises according to their progress. However, a clear explanation requires the analysis of other aspects, given that literature [
      • Chughtai M.
      • Elmallah R.
      • Mistry J.
      • Bhave A.
      • Cherian J.
      • McGinn T.
      • et al.
      Nonpharmacologic Pain Management and Muscle Strengthening following Total Knee Arthroplasty.
      ] reports that pain management after TKA typically occurs with pharmacological and non-pharmacological therapies such as transcutaneous electrical stimulation and cryotherapy, whose use is not always described in the study protocols.
      The results obtained at short-term FU for pain are not confirmed by the outcomes of function and mobility measured with the 6MWT, in fact there are no differences between the two groups in the same FU. The mobility results show no significant differences at the short- and medium-term FU, while at long-term FU our results are equal to those presented in the previous review by Buhagiar et al. [
      • Buhagiar M.A.
      • Naylor J.M.
      • Harris I.A.
      • Xuan W.
      • Adie S.
      • Lewin A.
      Assessment of Outcomes of Inpatient or Clinic-Based vs Home-Based Rehabilitation After Total Knee Arthroplasty: A Systematic Review and Meta-analysis.
      ], as the four recent studies [
      • Xu T.
      • Yang D.
      • Liu K.
      • Gao Q.
      • Lu H.
      • Qiao Y.
      • et al.
      Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study.
      ,
      • Crawford D.A.
      • Duwelius P.J.
      • Sneller M.A.
      • Morris M.J.
      • Hurst J.M.
      • Berend K.R.
      • et al.
      2021 Mark Coventry Award: Use of a smartphone-based care platform after primary partial and total knee arthroplasty: a prospective randomized controlled trial.
      ,
      • Prvu Bettger J.
      • Green C.L.
      • Holmes D.N.
      • Chokshi A.
      • Mather R.C.
      • Hoch B.T.
      • et al.
      Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty.
      ,
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ] added in this review did not use the 6MWT.
      Relative to knee flexion ROM results similar to those of pain outcome were found at short-term FU, however 2 degrees of greater flexion achieved in the unsupervised group is not clinically significant, indeed, as reported by Correia et al. [
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ] there are no MCID validated for knee range of motion in patients with TKA. Only the study by Stratford et al. [
      • Stratford P.W.
      • Kennedy D.M.
      • Robarts S.F.
      Modelling knee range of motion post arthroplasty: clinical applications.
      ] reported a Minimal Detectable Change at a 90 % confidence interval of 9.6 degrees for knee flexion and 6.3 degrees for knee extension in patients after TKA.
      A previous review [
      • Papalia R.
      • Vasta S.
      • Tecame A.
      • D’adamio S.
      • Maffulli N.
      • Denaro V.
      Home-based vs supervised rehabilitation programs following knee surgery: A systematic review.
      ] comparing home-based versus supervised rehabilitation pointed out that numerous variables such as comorbidities and motivation could influence the results. In addition to these variables, the difference in the results between supervised and unsupervised could be affected by the characteristics of the population. In fact, it’s plausible that a younger population could achieve greater results with supervised rehabilitation as shown in a study [
      • Rhim H.C.
      • Lee J.H.
      • Lee S.J.
      • Jeon J.S.
      • Kim G.
      • Lee K.Y.
      • et al.
      Supervised Rehabilitation May Lead to Better Outcome than Home-Based Rehabilitation Up to 1 Year after Anterior Cruciate Ligament Reconstruction.
      ] on a population of younger patients undergoing ACL reconstruction and therefore deserve to be better investigated.
      The strength of this review is the inclusion of high-level studies given that all included studies were randomized trials, although the study by Correia et al. [
      • Correia F.D.
      • Nogueira A.
      • Magalhães I.
      • Guimarães J.
      • Moreira M.
      • Barradas I.
      • et al.
      Home-based Rehabilitation With A Novel Digital Biofeedback System versus Conventional In-person Rehabilitation after Total Knee Replacement: a feasibility study.
      ] used a geographic criterion of randomization. However, some limitations need to be mentioned. Firstly, the number of studies did not allow the evaluation of publication bias for the outcomes evaluated in the meta-analysis. Secondly, it is important to mention the substantial heterogeneity in the choice of the tools used and the outcomes assessed by the individual studies. To address this issue, the Osteoarthritis Research Society International (OARSI) recommends five tests: the 30-s chair-stand test, 40 m fast-paced walk test, a stair-climb test, timed up-and-go test and 6-min walk test; the first three were recommended as the minimal core set of performance-based tests [
      • Dobson F.
      • Hinman R.S.
      • Roos E.M.
      • Abbott J.H.
      • Stratford P.
      • Davis A.M.
      • et al.
      OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis.
      ]. To obtain results that can be compared between the studies it is desirable that future RCTs use the tests suggested by OARSI. Furthermore, in this review no distinction was made between the different types of TKAs [
      • Longo U.G.
      • Ciuffreda M.
      • D’Andrea V.
      • Mannering N.
      • Locher J.
      • Denaro V.
      All-polyethylene versus metal-backed tibial component in total knee arthroplasty.
      ,
      • Longo U.G.
      • Ciuffreda M.
      • Mannering N.
      • D'Andrea V.
      • Locher J.
      • Salvatore G.
      • et al.
      Outcomes of Posterior-Stabilized Compared with Cruciate-Retaining Total Knee Arthroplasty.
      ,
      • Longo U.G.
      • Ciuffreda M.
      • Mannering N.
      • D’Andrea V.
      • Cimmino M.
      • Denaro V.
      Patellar Resurfacing in Total Knee Arthroplasty: Systematic Review and Meta-Analysis.
      ,
      • Longo U.G.
      • Candela V.
      • Pirato F.
      • Hirschmann M.T.
      • Becker R.
      • Denaro V.
      Midflexion instability in total knee arthroplasty: a systematic review.
      ] that could influence the outcomes.
      We also observed a total lack of assessments related to the quality of walking, as we pointed out in a previous review [

      Bravi M, Santacaterina F, Bressi F, Papalia R, Campi S, Sterzi S, et al. Does Posterior Cruciate Ligament Retention or Sacrifice in Total Knee Replacement Affect Proprioception? A Systematic Review. J Clin Med 2021, Vol 10, Page 3470 2021;10:3470. https://doi.org/10.3390/JCM10163470.

      ]. Given the current availability of rapid and valid gait analysis systems [
      • Bravi M.
      • Gallotta E.
      • Morrone M.
      • Maselli M.
      • Santacaterina F.
      • Toglia R.
      • et al.
      Concurrent validity and inter trial reliability of a single inertial measurement unit for spatial-temporal gait parameter analysis in patients with recent total hip or total knee arthroplasty.
      ,
      • Boekesteijn R.J.
      • Smolders J.M.H.
      • Busch V.J.J.F.
      • Geurts A.C.H.
      • Smulders K.
      Independent and sensitive gait parameters for objective evaluation in knee and hip osteoarthritis using wearable sensors.
      ,
      • Webster K.E.
      • Wittwer J.E.
      • Feller J.A.
      Validity of the GAITRite® walkway system for the measurement of averaged and individual step parameters of gait.
      ,
      • Bravi M.
      • Massaroni C.
      • Santacaterina F.
      • Di Tocco J.
      • Schena E.
      • Sterzi S.
      • et al.
      Validity Analysis of WalkerViewTM Instrumented Treadmill for Measuring Spatiotemporal and Kinematic Gait Parameters.
      ], future studies should take into account the evaluation of gait parameters to evaluate possible correlation of these parameters with clinical and functional alterations using reliable tools [
      • Longo U.G.
      • De Salvatore S.
      • Di Naro C.
      • Sciotti G.
      • Cirimele G.
      • Piergentili I.
      • et al.
      Unicompartmental knee arthroplasty: the Italian version of the Forgotten Joint Score-12 is valid and reliable to assess prosthesis awareness.
      ].Significant heterogeneity was found on the modality of unsupervised PT administered to patients: some authors used printed sheets or manuals with exercises, others used exercise videos loaded on specific web or smartphone applications, therefore, future studies should clarify which of these modalities offers the best results. Finally, we found a low level of reporting the rehabilitation protocols used by the various studies; this must certainly be considered because different protocols of exercise could have influenced the clinical results obtained.
      In the future, standardized indicators should be identified to predict which population is the most appropriate for each of the two approaches. For example, assigning patients with greater impairment the supervised physiotherapy in order to optimize the cost-benefit ratio associated with the rehabilitation of this population.

      5. Conclusion

      This systematic review did not show a significant clinical difference in improving pain, function, and mobility outcomes after TKA between supervised PT and unsupervised PT. Therofore, it would appear that supervised rehabilitation did not had additional benefits compared to unsupervised rehabilitation.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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