“Try PT First” is a tagline we all live by. As PTs, we know that many conditions can be improved with our skill set. Sometimes, though, we see patients whose structure is so significantly impaired that we can make only a negligible change. Total joint replacement is one example. Fortunately, these are highly successful surgeries, and PTs see patients regain a significant amount of mobility afterward.

The Case for Prehab

We often hear the word prehab, in the literature and in conversations with patients. The idea behind any prehab program is to improve the patient’s range of motion and strength before surgery, with the goal of improving post-operative outcomes. It makes sense to any healthcare professional and patient: the better you go in, the better you come out, right?

As a treatment, prehab is safe, with little to no harm. The patient gets a head start on rehabilitation, gets to know their therapist and learns what to expect after surgery. Interventions may also overlap before and after surgery, which suggests patients may adapt more easily post-op. Sounds good to me, but is there evidence to support it?

What the Updated Guideline Says

An update to the clinical practice guideline for PT management of total knee replacement was recently published in Physical Therapy (PTJ). In its section on prehabilitation, the authors found strong evidence that prehab has a positive short-term effect after surgery on strength, function and pain, though they noted the evidence was not completely definitive.

There was little evidence on whether prehab affects hospital stay, readmission or revision rates. The prehab programs studied also varied widely in amount of exercise, length and exercise selection.

Image spot (optional): therapist measuring knee range of motion

Weighing Benefit and Harm

When benefit and harm are weighed, prehab comes out on top in my mind. There is little risk to the patient when PTs take objective measures, actively listen to their patients and set appropriate exercise doses. Most prehab patients come in for only a few visits before surgery, and in the current insurance landscape, visits are valuable, so economic factors must be weighed as well.

Closing Thoughts

Prehab is safe and can be effective in the short term. As always, we must consider patient factors, especially current physical status, access to PT and insurance limitations.