Mental stimulation strategies for enhancing postoperative recovery after total knee replacement: a systematic review and meta-analysis
Autori
Andrea Giacovazzo – [Physical Medicine and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy]
Luca Turone – [Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy]
Lisa Berti – [1) Physical Medicine and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy 2) Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Italy]
Riccardo Rosa – [Physical Medicine and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy]
Daniela Platano – [1) Physical Medicine and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy 2) Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Italy]
Marco Pietro Parente – [Center for Mind/Brain Sciences-CiMeC, University of Trento, Rovereto, Italy]
Background and aims
Rehabilitation following total knee replacement (TKR) traditionally involves joint mobilization, active and functional exercises[1]. Recent researches attempted to integrate mirror-neuron system stimulation techniques into traditional TKR rehabilitation, and the results seem promising [2]. For this reason, this systematic review aimed to compare the effectiveness of adding mental stimulation strategies to conventional physiotherapy versus conventional physiotherapy alone in improving functional outcomes after TKR.
Methods
We conducted a systematic review and meta-analysis of Randomized Controlled Trials (RCTs). Two authors independently searched the PubMed, CENTRAL, and Web of Science databases for articles comparing mental stimulation in addition to conventional physiotherapy to conventional physiotherapy alone after TKR. The same authors independently extracted data, applied the Cochrane Risk of Bias 2 (RoB 2.0)[3], conducted meta-analyses, and applied the GRADE for the certainty of evidence. Primary outcomes included pain, quadriceps strength, passive Range of Motion (pROM), and active extension range of motion. Secondary outcomes included mobility and motor function. Subgroup analysis was performed for the primary outcomes (pain and pROM), categorizing studies according to the type of mental stimulation technique used.
Results
We included 11 RCTs (324 patients). Meta-analyses showed effects favoring mental stimulation in addition to conventional physiotherapy over conventional physiotherapy alone in reducing pain (mean difference [MD] = 1.23 cm, 95% confidence interval [CI] = 0.72-1.75; 9 studies; low certainty of evidence) and improving quadriceps strength (standardized mean difference = 0.61, 95%, CI = 0.21-1.02; 6 studies; low certainty of evidence). No significant improvements were found for pROM (MD = 1.68°, 95% CI = -1.55-4.91; 6 studies; very low certainty of evidence) and active extension range of motion (MD=0.15°, 95% CI = -0.28-0.75; 4 studies; very low certainty of evidence). For the secondary outcomes, meta-analyses showed significant improvements in both mobility and motor function. Subgroup analysis revealed that both Action Observation Training (AOT) and Motor Imagery (MI) in addition to conventional physiotherapy provided greater benefits for the outcome pain than physiotherapy alone. In contrast, neither technique appeared to offer additional benefits for pROM.
Conclusion
Our findings support the use of mental stimulation techniques in addition to conventional physiotherapy to enhance motor and functional recovery after knee replacement. Nevertheless, the overall low certainty of evidence highlights the need for further studies to identify the most effective approaches, taking into account patient-specific characteristics.
REFERENCES
- Jette DU, Hunter SJ, Burkett L, Langham B, Logerstedt DS, Piuzzi NS, et al. Physical Therapist Management of Total Knee Arthroplasty. Physical Therapy 2020;100(9):1603–31.
- Rizzolatti G, Fabbri-Destro M, Nuara A, Gatti R, Avanzini P. The role of mirror mechanism in the recovery, maintenance, and acquisition of motor abilities. Neuroscience & Biobehavioral Reviews 2021;127:404–23.
- Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019;366:l4898.