Supervised neuromuscular exercise prior to hip and knee replacement: 12-month clinical effect and cost-utility analysis alongside a randomised controlled trial

Linda Fernandes, Ewa M Roos, Søren Overgaard, Allan Villadsen, Rikke Søgaard, Linda Fernandes, Ewa M Roos, Søren Overgaard, Allan Villadsen, Rikke Søgaard

Abstract

Background: There are indications of beneficial short-term effect of pre-operative exercise in reducing pain and improving activity of daily living after total hip replacement (THR) and total knee replacement (TKR) surgery. Though, information from studies conducting longer follow-ups and economic evaluations of exercise prior to THR and TKR is needed. The aim of the study was to analyse 12-month clinical effect and cost-utility of supervised neuromuscular exercise prior to THR and TKR surgery.

Methods: The study was conducted alongside a randomised controlled trial including 165 patients scheduled for standard THR or TKR at a hospital located in a rural area of Denmark. The patients were randomised to replacement surgery with or without an 8-week preoperative supervised neuromuscular exercise program (Clinical Trials registration no.: NCT01003756). Clinical effect was measured with Hip disability and Osteoarthritis Outcome Score (HOOS) and Knee injury and Osteoarthritis Outcome Score (KOOS). Quality adjusted life years (QALYs) were based on EQ-5D-3L and Danish preference weights. Resource use was extracted from national registries and valued using standard tariffs (2012-EUR). Incremental net benefit was analysed to estimate the probability for the intervention being cost effective for a range of threshold values. A health care sector perspective was applied.

Results: HOOS/KOOS quality of life [8.25 (95% CI, 0.42 to 16.10)] and QALYs [0.04 (95% CI, 0.01 to 0.07)] were statistically significantly improved. Effect-sizes ranged between 0.09-0.59 for HOOS/KOOS subscales. Despite including an intervention cost of €326 per patient, there was no difference in total cost between groups [€132 (95% CI -3942 to 3679)]. At a threshold of €40,000, preoperative exercise was found to be cost effective at 84% probability.

Conclusion: Preoperative supervised neuromuscular exercise for 8 weeks was found to be cost-effective in patients scheduled for THR and TKR surgery at conventional thresholds for willingness to pay. One-year clinical effects were small to moderate and favoured the intervention group, but only statistically significant for quality of life measures.

Trial registration: ClinicalTrials.gov ( NCT01003756 ) October 28, 2009.

Keywords: Arthroplasty; Cost-benefit analysis; Exercise; Osteoarthritis; Replacement.

Figures

Fig. 1
Fig. 1
Flow diagram of patients participating in this study. * Co-morbidities (n = 97). ◆ Previous fracture in or adjacent to the joint (n = 13) (1 knee). ◆ Inflammatory arthritis (n = 11) (5 knee). ◆ Revision arthroplasty (n = 7) (4 knee). ◆ Previously enrolled with another joint (n = 9) (7 knee). ◆ Unicompartemental replacement (knee) (n = 27). ◆ Bilateral procedure in same session or within 3 month (n = 16). ◆ Necrosis of the femoral head (hip) (n = 6). ◆ Neurological disorders (n = 6), Hemiparesis (n = 2), Parkinsons Disorder (n = 2), Dementia (n = 2). ◆ Dysplasia of the femoral head (n = 1). ◆ Possible cancer metastasis in proximal femur (n = 1). ** The Danish Healthcare System has a one month treatment guarantee. Entering this study meant all patients accepting an additional wait of up to 5 weeks in comparison to the treatment guarantee. After randomization, this additional wait applied only for patients randomized to the 8 week exercise intervention. The control group was operated on when originally scheduled
Fig. 2
Fig. 2
Cost effectiveness acceptability curves for incremental net monetary benefit to estimate the probability for the intervention being cost effective at conventional thresholds for willingness to pay. Health care perspective, Health Care Sector perspective (base-case analysis); Complete item response, only complete item response of the EQ-5D-3L included in the analysis; Health care & patients’ expenses, Health Care Sector and patients’ own expenses perspective; No adjustment for baseline, adjustments for baseline EQ-5D-3L scores were not included; Per-protocol, only patients attending 12 or more exercise sessions were included in the analysis

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