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Preoperative education for hip or knee replacement

  1. Steve McDonald1,*,
  2. Matthew J Page2,
  3. Katherine Beringer3,
  4. Jason Wasiak4,
  5. Andrew Sprowson5,†

Editorial Group: Cochrane Musculoskeletal Group

Published Online: 13 MAY 2014

Assessed as up-to-date: 31 MAY 2013

DOI: 10.1002/14651858.CD003526.pub3


How to Cite

McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD003526. DOI: 10.1002/14651858.CD003526.pub3.

Author Information

  1. 1

    School of Public Health & Preventive Medicine, Monash University, Australasian Cochrane Centre, Melbourne, Victoria, Australia

  2. 2

    Monash University, School of Public Health & Preventive Medicine, Melbourne, Victoria, Australia

  3. 3

    University of Melbourne, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia

  4. 4

    The Epworth Hospital, Department of Radiation Oncology, Richmond, Australia

  5. 5

    University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Warwickshire, UK

  1. Deceased

*Steve McDonald, Australasian Cochrane Centre, School of Public Health & Preventive Medicine, Monash University, Level 1, 549 St Kilda Road, Melbourne, Victoria, 3004, Australia. steve.mcdonald@monash.edu.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 13 MAY 2014

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Characteristics of included studies [ordered by study ID]
Beaupre 2004

MethodsRandomised parallel group trial.


Participants131 participants undergoing total knee replacement. Intervention group: 39 women, 26 men (mean age 67 years, SD 7); control group: 33 women, 33 men (mean age 67 years, SD 6).

Inclusion criteria: diagnosis of non-inflammatory arthritis; aged 40-75 years; ability to understand English, or use a translator.

Exclusion criteria: none stated.

Location: Canada.


InterventionsIntervention group (n = 65) received an education programme consisting of instructions on crutch walking, bed mobility and transfers, and postoperative range of motion routine. Plus an exercise programme designed to improve knee mobility and strength, similar to the post-surgical exercise routine. Participants attended 3 sessions/week for 4 weeks (12 treatment sessions in total) within 6 weeks of surgery.

Control group (n = 66) continued with regular activities until surgery.


OutcomesPain, stiffness and function (WOMAC 100-mm VAS (0-100 points) higher score represented less pain, stiffness and dysfunction); overall health status (SF-36 (0-100 points) higher score represented better health status); active knee range of motion; health service utilisation (re-admission, further surgery, etc.); healthcare costs; length of hospital stay; complications. Participants were assessed pre- and post-intervention and 3, 6 and 12 months postoperatively.


NotesWOMAC scores were transformed to a range from 0 to 100 points, where high scores indicated less pain and dysfunction.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "Patients were randomized, in blocks of 20 patients, ..."

Comment: no description of how the sequence within each block was generated but probably adequate.

Allocation concealment (selection bias)Low riskQuote: "Randomization was performed using consecutively numbered opaque envelopes."

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskQuote: patients had to be "willing to undertake the intervention and attend follow-up visits..."
Comment: patients were aware of the intervention and which group they were allocated to, making blinding of self-reported outcomes not feasible.

Blinding (performance bias and detection bias)
Objective outcomes
Low riskQuote: "... a randomized clinical trial with blinded assessment of outcomes by a physical therapist not involved with the intervention."

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: the number, reasons and distribution of exclusions between the 2 groups was adequately described. At least 80% of follow-up assessments were completed. Missing data from the 3-month and 6-month assessments were imputed using the 'cold-decking' strategy, which was robust when checked in a sensitivity analysis.

Selective reporting (reporting bias)Unclear riskComment: all outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Butler 1996

MethodsRandomised parallel group trial.


Participants80 participants aged 17-85 years (mean 63, SD 13) undergoing total hip replacement. Intervention group: 18 women, 14 men (mean age 64 years, SD 13); control group: 22 women, 26 men (mean age 62 years, SD 13).

Inclusion criteria: ability to read English.

Exclusion criteria: previous hip replacement.

Location: Canada.


InterventionsIntervention group (n = 32) posted an 18-page teaching booklet as part of the pre-admission package 4-6 weeks before surgery.

Control group (n = 48) posted pre-admission package only (containing information of a general nature).


OutcomesAnxiety (Spielberger State-Trait Anxiety Inventory (20-80 points) higher score represented greater anxiety); length of hospital stay; practising of pre-hospital preparatory exercises; attendance at physiotherapy and occupational therapy sessions; participant satisfaction. Participants were assessed pre- and post-intervention.


NotesOn admission, both groups were treated identically. Patient satisfaction ratings were only taken just before discharge, by which time both groups had received the same information. An overall satisfaction rating was not obtained. Instead, ratings were given for each of six questions. The data entered in the review for patient satisfaction relate to the question "How satisfied were you with the amount of information you received about your hip joint and what a total hip replacement is?".


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: sequence generation not described.

Allocation concealment (selection bias)Low riskQuote: "A patient guide booklet was randomly added to half of the preadmission packages mailed out to THR [total hip replacement] patients."

Comment: random allocation of the patient guide booklet was done by a clerk in the Admissions Department (and was concealed from the trial investigators) - personal communication with author.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: patients were not aware of the trial when booklets were randomly added to half the packages mailed out. Only at admission were patients informed of the purpose of the trial, gave their consent and then completed the anxiety inventory. Knowledge of the intervention could have influenced responses, especially those relating to anxiety and satisfaction with information.

Blinding (performance bias and detection bias)
Objective outcomes
Unclear riskComment: unclear if trial personnel were blinded.

Incomplete outcome data (attrition bias)
All outcomes
High riskQuote: "Eight additional patients were excluded because they were discharged before their predischarge data could be collected."

Comment: not clear if these 8 participants were undergoing hip replacement for the first time (and thus would have been included in the analysis).

There were missing data for all outcomes (in addition to the 8 participants mentioned above) ranging from 2 to 12 participants (length of stay). The reasons for drop-outs are not stated.

Selective reporting (reporting bias)Unclear riskComment: outcomes stated in the methods were reported in the results. Outcome data for satisfaction were not reported in sufficient detail in the paper but were provided by the study author on request. Without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Clode-Baker 1997

MethodsRandomised parallel group trial.


Participants78 participants undergoing total hip replacement (52 women, 26 men; aged ≤ 65 years (25 participants), aged 66-74 years (27 participants), aged ≥ 75 years (27 participants)).

Inclusion criteria: none stated.

Exclusion criteria: none stated.

Location: Leicester, UK.


InterventionsIntervention group (n = 41) was posted information (video and booklet) about the procedure and postoperative recovery about 4 weeks before surgery. On admission, offered the chance to see life-size plastic model bones.

Control group (n = 37) received no preadmission video or booklet but were seen routinely on admission by nursing staff who provided information about the hospital stay.


OutcomesPain (descriptive ordinal scale); general health state (Nottingham Health Profile); stress (Stress Arousal Checklist); anxiety and depression (Hamilton Anxiety and Depression Scale); days to mobilisation; length of hospital stay; sleep disturbance; satisfaction with information received. Participants were assessed pre-intervention, 1 week postoperatively and 1 week post-discharge.


Notes25% of participants were undergoing their second primary total hip replacement and "nearly all" of these participants were in the intervention group.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Those who agreed to participate were randomized by an independent statistician..."

Comment: very likely that the sequence was randomly generated if done by an independent statistician.

Allocation concealment (selection bias)Low riskQuote: "...were randomized by an independent statistician..."

Comment: likely to be adequate since allocation was independent of the trial personnel.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: no description of any attempt to blind patients and blinding is unlikely to have been possible.

Blinding (performance bias and detection bias)
Objective outcomes
Unclear riskQuote: "Nursing staff was not told to which group patients had been allocated."

Comment: unlikely to have much impact on the results as most outcomes were participant reported. Participants could easily inadvertently disclose their group allocation to nursing staff.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: reasons for initial exclusions (cancelled or postponed operations) adequately described. Data on several participants were missing for various outcomes without any explanation, though the impact of missing data is unlikely to seriously affect the continuous outcomes.

Selective reporting (reporting bias)High riskComment: all outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results. Outcome data were only reported as medians and IQRs, so data were unable to be included in meta-analyses.

Other biasLow riskComment: no other sources of bias identified.

Cooil 1997

MethodsRandomised parallel group trial with randomisation within matched pairs based on age, gender and socioeconomic status.


Participants42 participants (30 women, 12 men) undergoing total hip replacement. Intervention group: mean age 69 years (SD 8, range 54 to 84); control group: mean age 69 years (SD 8, range 56 to 84).

Inclusion criteria: unilateral total hip replacement.

Exclusion criteria: previous hip replacement surgery, unable to read or hear.

Location: Essex, UK.


InterventionsIntervention group (n = 21) given an information sheet containing instructions for the postoperative protocol, a list of exercises plus advice on harmful and beneficial postoperative activities. Participants received verbal explanation of the content and were taught exercises and activities through demonstration and practice by a 'physiotherapy helper'.

Control group (n = 21) given the same information sheet, asked to read and follow instructions but received no further contact with demonstrator.


OutcomesParticipant co-operation and understanding (recall of exercises and advice on first postoperative day); participant satisfaction with content and delivery of information. Participants were assessed 1 and 2 days postoperatively.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The first subject in each matched pair was randomly assigned to one of the two groups..."

Comment: sequence generation not stated.

Allocation concealment (selection bias)Unclear riskComment: allocation concealment not described.

Blinding (performance bias and detection bias)
Self-reported outcomes
Low riskQuote: patients were "told that the aim of the trial was to evaluate the physiotherapy service."
Comment: likely the patients were not fully aware of the differences between the 2 groups.

Blinding (performance bias and detection bias)
Objective outcomes
Low riskQuote: "...patients were tested by an independent assessor, who had no previous contact with the patients and who was blind to the subject grouping."

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: data for 3 participants were missing for the recall scores but this is not explicitly reported or explained. Unlikely that this would adversely affect the overall results.

Selective reporting (reporting bias)Unclear riskComment: all outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Crowe 2003

MethodsRandomised parallel group trial.


Participants133 participants undergoing total hip replacement (65 participants) or total knee replacement (68 participants). Intervention group: 51 women, 14 men (mean age 67 years, SD 12); control group: 55 women, 13 men (mean age 71 years, SD 11).

Inclusion criteria: participants who were not functioning well; had limited social support or co-existing medical conditions, or both.

Exclusion criteria: participants who were functioning well despite their joint dysfunction, who were managing activities of daily living and had good carer support. General exclusions included people with limited English and who were undergoing a revision or second joint replacement within 2 years.

Location: Ontario, Canada.


InterventionsIntervention group (n = 65) received a preoperative education package (video, booklet plus information on length of stay, discharge criteria, respite care and diet). Some participants given tour of the hospital unit, demonstration of equipment, dietician counselling and social work input. All received individualised counselling from an occupational therapist.

Control group (n = 68) received 1 standard preoperative clinic visit (lasting about 7 hours) 1-2 weeks before surgery. Participants were informed about the hospital stay and the immediate postoperative phase.


OutcomesDays to eligibility for discharge; preoperative anxiety (Spielberger State-Trait Anxiety Inventory (20-80 points) higher score represented greater anxiety); length of hospital stay; days to mobilisation (out of bed, walking and climbing stairs).


NotesRandomisation resulted in uneven numbers of hip and knee replacements in each group. Data for hip and knee replacement groups were obtained from the study author.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Subjects were allocated to one of the two groups by means of a random number table and using a system of sealed envelopes."

Allocation concealment (selection bias)Low riskQuote: "Subjects were allocated to one of the two groups by means of a random number table and using a system of sealed envelopes."

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskQuote:"[Participants] were telephoned by the research coordinator who explained the trial. Oral assent was obtained, and the client signed an informed consent at his/her initial trial visit."
Comment: participants were unlikely to be blinded and this may impact self reported outcomes like anxiety. It was not possible to blind the in-hospital PT and OT staff as participants often choose to discuss previous rehabilitation with staff.

Blinding (performance bias and detection bias)
Objective outcomes
Low riskQuote: "Outcomes were measured in-hospital by an investigator who was blinded to group allocation."

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: incomplete outcome data not reported. It is unclear if there were missing data and if so, how this was handled. Results tables report continuous measures but omit the denominator.

Selective reporting (reporting bias)Unclear riskComment: all outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasHigh riskThe control group had significantly poorer overall function prior to surgery (i.e. a pre-existing difference that favoured the treatment group).

Daltroy 1998

MethodsRandomised 4-arm trial using a 2 x 2 factorial design stratified by joint and age (18-70 years, > 70 years).


Participants222 participants undergoing total hip replacement (n = 104) or total knee replacement (n = 118) (146 women, 76 men; mean age 64 years, SD 12).

Inclusion criteria: participants scheduled for knee or hip replacement.

Exclusion criteria: previous hip or knee surgery, inability to speak English or fill out questionnaires.

Location: Boston, USA.


InterventionsInformation group (n = 58) received a 12-minute audio-tape slide programme from a research assistant the day before surgery on the postoperative in-hospital rehabilitation experience. A pamphlet was also left at the bedside.

Relaxation group (n = 58) received training in Benson's Relaxation Response with a bedside audiotape the day before surgery.

Information plus relaxation group (n = 52) received the information intervention followed by relaxation training.

Control group (n = 54) received neither intervention.


OutcomesLength of hospital stay; anxiety on day 4 (Spielberger State-Trait Anxiety Inventory (20-80 points) higher score represented greater anxiety); pain (1-5 ordinal scale, where 1 represented least pain and 5 most pain; and charted pain medication used during the first 4 days after surgery); mental status on day 4 (Mini-Mental State Examination (0-30 points) higher score represented normal cognition); use of continuous passive motion machine; usefulness of intervention materials.


NotesData from the Information plus relaxation group were excluded from the analyses because our inclusion criteria specified that the education/information intervention should be the sole component of the intervention.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "...were assigned randomly to one of the treatment groups."

Comment: sequence generation not described.

Allocation concealment (selection bias)Unclear riskComment: allocation concealment not described.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: baseline data were collected before randomisation, so these data are unaffected by group allocation. No description of any attempt to blind patients and blinding is unlikely to have been possible.

Blinding (performance bias and detection bias)
Objective outcomes
Low riskQuote: "In order to conceal the patient's group assignment from nurses, rehabilitation staff, and surgeons, all questionnaires and the intervention itself were administered by either of two research assistants."

Comment: staff providing postoperative care were blinded but the research assistants administering the intervention and the outcome questionnaires were not blind. The trial authors reported that staff responses at patient discharge indicated that blinding was successfully implemented among the staff.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "Five patients had incomplete followup questionnaire data and were excluded from all followup analyses except length of stay..."

Comment: exclusions pre-randomisation were described. Post-randomisation, 1 participant was excluded because of postoperative complications unrelated to the surgery, and 5 had incomplete follow-up questionnaire data. Neither the reasons for incomplete data nor the distribution between groups were given; however, the impact was likely to be minimal because of the relatively small number of missing participants (less than 3%), plus the outcomes were continuous measures.

Selective reporting (reporting bias)High riskComment: results of all outcomes were partially reported. Trialists only reported means and SDs for both groups combined, and presented mean values of each group, with no measures of variation, in figure format. Trialists also reported that for all outcomes, the differences between groups was not statistically significant. Attempts to retrieve missing data from trialists were unsuccessful. All outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Doering 2000

MethodsRandomised parallel group trial.


Participants100 participants undergoing total hip replacement. Intervention group: 21 women, 25 men (mean age 59 years, SD 11); control group: 17 women, 37 men (mean age 60 years, SD 9).

Inclusion criteria: aged ≥ 18 years, osteoarthritis of the hip.

Exclusion criteria: previous hip surgery, co-morbidity associated with severe pain, scheduled elective hip replacement, co-morbidity that might alter cortisol and catecholamine excretion, psychiatric co-morbidity.

Location: Innsbruck, Austria.


InterventionsIntervention group (n = 46) shown a 12-minute video in the presence of an investigator the night before surgery; film contained procedural information (pre- and postoperative), behavioural instructions and information about a participant's likely sensory experiences.

Control group (n = 54) received preoperative information delivered by a surgeon and anaesthetist, and routine information sheets.


OutcomesAnxiety (Spielberger State-Trait Anxiety Inventory (20-80 points) higher score represented greater anxiety); depression (von Zerssen Depression Scale; scoring system not reported); days to mobilisation (standing and climbing stairs); length of hospital stay; pain (100-mm VAS, and postoperative analgesics); blood pressure; cortisol excretion. Participants were assessed preoperatively and 2 days postoperatively.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Patients... were randomly assigned to the preparation or control group."

Comment: randomisation was performed by means of chance numbers (personal communication)

Allocation concealment (selection bias)Unclear riskComment: allocation concealment not described.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: No description of any attempt to blind participants; participants likely to be aware of group allocation and this may have influenced participants' responses to the anxiety questionnaire.

Blinding (performance bias and detection bias)
Objective outcomes
Low riskQuote: "Physicians of the Departments of Orthopedics and Anesthesia were blind to the assignment of patients to groups."

Comment: for measures of mobility and use of analgesics outcome assessment was blinded.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: there does not appear to be any withdrawals (e.g. cortisol data were complete) but missing values are not explicitly reported.

Selective reporting (reporting bias)Unclear riskComment: data for all continuous outcomes were presented as mean values without measures of variation in figure format; however, trialists provided means and SDs on request. All outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Giraudet 2003

MethodsRandomised parallel group trial.


Participants100 participants undergoing total hip replacement. Intervention group: 24 women, 24 men (mean age 63 years, SD 9); control group: 32 women, 20 men (mean age 64 years, SD 10).

Inclusion criteria: first elective total hip replacement for primary hip osteoarthritis.

Exclusion criteria: secondary osteoarthritis or another disease of the hip, age > 80 years, American Society of Anesthesiologists physical status score > 2, Montgomery and Asberg Depression Rating scale > 30, inability to speak French, sight impairment, living far from Paris.

Location: Paris, France.


InterventionsIntervention group (n = 48) attended a half-day, small-group (3-6 per group) multidisciplinary information session 2 to 6 weeks before surgery. The multidisciplinary team consisted of a rheumatologist, surgeon, anaesthetist, physiotherapist and psychiatrist. The programme was standardised but the multidisciplinary team varied. Participants also received the usual verbal information and standard information leaflet.

Control group (n = 52) received usual verbal information from the surgeon and anaesthetist (based on the participant's personality, psychology, expectations and needs) plus the standard information leaflet that contained practical information, advice and warnings on hospitalisation and rehabilitation.


OutcomesAnxiety pre- and postoperatively (Spielberger State-Trait Anxiety Inventory (20-80 points) higher score represented greater anxiety); pain (VAS (0-100 points) a higher score represented worse pain, and personal analgesic use diary); days to standing; length of hospital stay; rehabilitation; participant satisfaction (range 0-100); complications. Participants were assessed preoperatively and 1 and 7 days postoperatively.


NotesAll participants were permitted to stand on day 2, but the day participants were permitted to walk depended on the person's recovery.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "The allocation sequence was generated by the random placement of thoroughly shuffled marked cards..."

Allocation concealment (selection bias)Low riskQuote: "... the random placement of thoroughly shuffled marked cards into sequentially numbered sealed, opaque envelopes by the outpatient clinic assistant..."

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: no description of any attempt to blind participants and blinding is unlikely to have been possible. Knowledge of being in the intervention group may have influenced participants' use of analgesics and their anxiety levels.

Blinding (performance bias and detection bias)
Objective outcomes
Unclear riskComment: blinding of outcome assessors not reported, though this could have been done.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "All but one patient (control group) completed the trial. This patient withdrew... refusing to complete the State Anxiety Inventory after surgery."

Selective reporting (reporting bias)Unclear riskComment: all outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Gocen 2004

MethodsRandomised parallel group trial.


Participants59 participants undergoing total hip replacement. Intervention group: 13 women, 16 men (mean age 47 years, SD 11); control group: 8 women, 22 men (mean age 56 years, SD 14).

Inclusion criteria: osteoarthritis of the hip joint, no previous physiotherapy for hip osteoarthritis.

Exclusion criteria: other chronic diseases or arthritis in other joints necessitating treatment.

Location: Izmir, Turkey.


InterventionsIntervention group (n = 29) were given stretching and strengthening exercises 3 times daily for 8 weeks before surgery, and an education programme that included advice on movements to avoid, use of devices and activities of daily living.

Control group (n = 30) received neither the preoperative exercises nor the education programme.


OutcomesFunction* (Harris Hip Score (maximum 100 points) 90-100: good function and excellent results, 80-90: good, 70-80: fair, < 70: poor results); range of motion; pain (VAS; units of the scale not reported); days to mobility (walking and climbing stairs); length of hospital stay. Participants were assessed preoperatively, at discharge, and 3 months and 2 years postoperatively.


Notes*Harris Hip Score data at 2 years included in Analysis 1.2.

Both groups received the same postoperative and education programme beginning the day after surgery.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "The patients were randomly divided into two groups using a table of random numbers of a computer programme (Excel 2000)."

Allocation concealment (selection bias)Unclear riskQuote: "Even numbers were allocated to the control group and odd numbers to the trial group."

Comment: it is not clear who was involved in the allocating the participants or what steps were taken to conceal the random sequence.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: no description of any attempt to blind participants and blinding is unlikely to have been possible. Knowledge of being in the intervention group may have influenced participants' experience of pain.

Blinding (performance bias and detection bias)
Objective outcomes
Low riskQuote: "Postoperative treatment was performed by a physical therapist who was blinded to the patients' groups. ... All measurements were performed by a staff physical therapist who was blinded to the trial."

Comment: it is possible that participants could disclose which group they were in during treatment or measurement by the physiotherapist.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: 1 participant assigned to the trial group was not operated on because of cardiovascular problems and was excluded from the analysis. Data for the 59 participants that underwent surgery were available at discharge and 1-year follow-up. No mean or SD given for length of hospital stay.

Selective reporting (reporting bias)High riskComment: trialists reported measuring pain with VAS in the methods section, but no pain data were reported in the results section. Also, without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Johansson 2007

MethodsRandomised parallel group pre-post test design.


Participants123 participants undergoing total hip replacement. Intervention group: 32 women, 30 men (mean age 60 years); control group: 31 women, 30 men (mean age 65 years).

Inclusion criteria: aged ≥ 18 years, able to complete questionnaires.

Exclusion criteria: none stated.

Location: Finland.


InterventionsIntervention group (n = 62) received standard written education materials plus education using the concept map method that was delivered by 2 specially trained nurses 2 weeks before admission lasting 30-60 minutes. The concept map method involved counselling in biophysiological, functional, experiential, ethical, social and financial issues about care both pre- and postoperative.

Control group (n = 61) received standard written education materials only.


OutcomesParticipant knowledge (Orthopaedic Patient Knowledge Questionnaire); participant empowerment (Modified Empowerment Questionnaire); length of hospital stay; length of discussion at admission; need for further care. Participants were assessed preoperatively and at discharge.


NotesTrialists only reported that "The length of hospital stay was shorter among group A patients than in group B (A: M = 6.78 days; B: M = 8.18 days)". Requests for the SDs of each group were unsuccessful.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "A randomized two-group pre-test post-test design was used..."

Comment: sequence generation not described.

Allocation concealment (selection bias)Unclear riskComment: method of allocation not described.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskQuote: "Patients were informed about the purpose of the trial".
Comment: no description of any attempt to blind participants and blinding is unlikely to have been possible. Knowledge of being in the intervention group may have influenced how participants performed in the pre- and posttest questionnaires.

Blinding (performance bias and detection bias)
Objective outcomes
Unclear riskQuote: "The clinical outcomes... were gathered from patients' documents."

Comment: unclear if the staff responsible for participant discharge were part of the trial personnel; however, the risk of bias is likely to be minor.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: the number of post-randomisation drop-outs per group (11% in the intervention group and 16% in the control) and the reasons for the drop-outs were described. Continuous outcomes unlikely to be affected by the proportion of drop-outs.

Selective reporting (reporting bias)High riskComment: SDs for length of hospital stay were missing from the published report. All other outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Lilja 1998

MethodsRandomised parallel group trial.


Participants55 participants (median age 65 years) undergoing total hip replacement. Intervention group: 9 women, 13 men; control group: 8 women, 20 men.

Inclusion criteria: aged < 75 years.

Exclusion criteria: none stated.

Location: Angelholm, Sweden.


InterventionsIntervention group (n = 22) given extended formalised information concerning pre- and postoperative procedures by an anaesthetic nurse for 30 minutes the day before surgery.

Control group (n = 28) informed about pre- and postoperative routines by a ward nurse.


OutcomesAnxiety (Hospital Anxiety and Depression Scale (0-21 points) higher score represented greater anxiety); pain (VAS, ranging from 0 (no pain) to 10 (worst imaginable pain)); serum cortisol (radioimmunoassay). Participants were assessed preoperatively and 1 and 3 days postoperatively.


NotesAim of the trial was to evaluate effects of extended preoperative information on perioperative stress. 5 participants withdrew post-randomisation.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "... were randomized into two groups..."

Comment: sequence generation not described.

Allocation concealment (selection bias)Unclear riskComment: method of allocation not described.

Blinding (performance bias and detection bias)
Self-reported outcomes
Low riskQuote: "To avoid interventional bias, the patients were only informed that a trial was in progress, but were not informed about the aim and the design of the trial."

Blinding (performance bias and detection bias)
Objective outcomes
Low riskQuote: "The randomized design of the trial was kept from all personnel who came into contact with the patients except for the anaesthetic nurses who participated in the extended information. These nurses did not participate in any way in the postoperative registrations of stress, anxiety and pain."

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: reasons are given for the withdrawal of the 5 participants after randomisation and their distribution between the 2 groups; it is not clear whether some of these participants underwent surgery. The study authors stated there were no other exclusions but it was not clear if there were any missing data within each analysis because the sample size was not reported.

Selective reporting (reporting bias)High riskComment: trialists only reported mean values of each group with no measures of variation for all outcomes (and noted that the differences between groups on all outcomes were not statistically significant. Attempts to retrieve this missing data from trialists were unsuccessful. In addition, all outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

McDonald 2004

MethodsRandomised 3-arm trial.


Participants26 participants undergoing total knee replacement (mean age 72 years, SD 5, range 65 to 88). Intervention group: 8 women, 9 men (mean age 73 years, SD 6); control group: 7 women, 2 men (mean age 72 years, SD 7).

Inclusion criteria: aged ≥ 65 years, experiencing only non-malignant pain; able to communicate in English.

Exclusion criteria: previous hip or knee replacement, delirium or dementia.

Location: Connecticut, USA.


InterventionsIntervention group (n = 17) attended the standard preoperative class provided by the hospital and viewed a pain management and pain communication film.

Control group (n = 9) attended the standard preoperative class only.


OutcomesPain (Short Form of the McGill Pain Questionnaire, including 100-mm VAS for pain intensity and present pain intensity scale where a higher score represented worse pain). Patients were assessed 1 and 2 days postoperatively and 1 and 7 days post-discharge.


NotesThe purpose of the trial was to test the effects of teaching preoperative basic pain management and communication skills on postoperative pain. Data for the second comparison group (viewed pain management film only) were not included in the analysis.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Random assignment to group was accomplished through use of a table of random numbers."

Allocation concealment (selection bias)Unclear riskComment: method of allocation not stated.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: no description of any attempt to blind participants and blinding is unlikely to have been possible.

Blinding (performance bias and detection bias)
Objective outcomes
Low riskQuote: "The second author, who was blind to the older adults' conditions, obtained the postoperative pain measures after screening for delirium."

Incomplete outcome data (attrition bias)
All outcomes
High riskComment: study authors were explicit in stating how participants and data were handled, but some participants were removed due to a change in the protocol, and other participants were removed due to author interpretation. For example, all participants receiving hip replacements were removed from the analysis.

Selective reporting (reporting bias)Unclear riskComment: the study authors reported the reasons for the difference between outcome measures initially used, and outcomes included in the results. Without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasHigh riskComment: change in protocol described and justified on the basis of minimising confounds, but it was done after the initial data analysis.

McGregor 2004

MethodsRandomised parallel group trial.


Participants35 participants (25 women, 10 men; mean age 72 years, SD 9, range 51 to 92) undergoing total hip replacement. Intervention group: 19 participants (mean age 71 years, SD 9); control group: 20 participants (mean age 73 years, SD 10).

Inclusion criteria: none stated.

Exclusion criteria: revision or bilateral arthroplasty, previous hip joint surgery, co-existing morbidity, mental confusion, inadequate comprehension of English.

Location: London, UK.


InterventionsIntervention group (n = 19) attended a preoperative hip class 2-4 weeks before surgery and received an information booklet containing information about the surgery, pre- and postoperative stages and rehabilitation, including exercises. The preoperative class reinforced the information in the booklet and covered adaptations participants could make to their homes in the immediate postoperative period.

Control group (n = 20) received the standard preoperative management that included a description of the surgery and its risk. They did not receive an information booklet or attend a class.


OutcomesFunction (WOMAC, administered using the Likert Scale version, which ranges from 0 to 68 where a higher score represented more dysfunction*; Harris Hip Score (maximum 100 points) 90-100: good function and excellent results, 80-90: good, 70-80: fair, < 70: poor results; and Barthel Activities of Daily Living Index (0-20 points) higher score represented less dysfunction); pain (WOMAC Likert Scale version (0-20 points) higher score represented worse pain; and a VAS (0-10 points) higher score indicated worse pain**) and expectations of postoperative pain (VAS, units of measurement not reported); mood (Positive Affect Negative Affect Scale); fatigue (VAS, units of measurement not reported); satisfaction (VAS, units of measurement not reported); length of hospital stay; economic analysis (EuroQoL EQ-5D); complications. Participants were assessed preoperatively, at discharge, and 3 months postoperatively.


Notes*WOMAC function scale data at 3 months included in Analysis 1.2.

**Only the 0-10 VAS was included in the analysis of 'pain'.

Trialists only reported that "On average, patients in group A spent 15 days in the hospital for the surgical procedure, whereas patients in group B spent 18 days in the hospital". Requests for the SDs of each group were unsuccessful.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "...patients were allocated randomly into either group A or group B."

Comment: sequence generation not described.

Allocation concealment (selection bias)Unclear riskQuote: "...patients were randomized by age and not functional status."

Comment: how participants were stratified and whether allocation was concealed was not described.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: no description of any attempt to blind participants and blinding is unlikely to have been possible. Knowledge of being in the intervention group may have influenced participants' preoperative expectations of postoperative pain, mood and pain.

Blinding (performance bias and detection bias)
Objective outcomes
Unclear riskComment: not stated.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskQuote: "...4 patients [from the intervention group] were subsequently lost to review."

Comment: reasons for loss to follow-up not stated. Impact of incomplete data likely to be minimal because outcomes were all continuous measures. Not clear if the pre-discharge results included the 4 participants subsequently lost to review.

Selective reporting (reporting bias)High riskComment: SDs for length of hospital stay were missing from the published report. All other outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Santavirta 1994

MethodsRandomised parallel group trial.


Participants60 participants undergoing total hip replacement. Intervention group: 19 women, 8 men (mean age 59 years, SD 6); control group: 19 women, 14 men (mean age 58 years, SD 5).

Inclusion criteria: aged ≥ 18 years.

Exclusion criteria: previous major orthopaedic surgery, severe disabilities.

Location: Helsinki, Finland.


InterventionsIntervention group (n = 27) before admission received an 18-page patient information booklet covering all aspects of total hip replacement surgery and postoperative rehabilitation. On admission, participants had a 20- to 60-minute teaching session delivered by one of the investigators concerning total hip replacement surgery and rehabilitation that was individually planned according to each participant's specific situation.

Control group (n = 33) received the 18-page booklet only.


OutcomesPatient knowledge (disease, treatment and rehabilitation); patient satisfaction with information provided; patient compliance (questionnaire); complications. Participants were assessed preoperatively and 2-3 months postoperatively.


NotesMeasurements taken on admission to hospital and 2-3 months postoperatively.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "... patients were randomly divided into an experimental and to a control group."

Comment: sequence generation not described.

Allocation concealment (selection bias)Unclear riskComment: method of allocation not described.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: no description of any attempt to blind participants and blinding is unlikely to have been possible. Knowledge of being in the intervention group may have resulted in participatns trying to retain information and influenced the way they felt about the information.

Blinding (performance bias and detection bias)
Objective outcomes
Unclear riskQuote: "Orthopaedic surgeons who took care of and operated on these patients were knowledgeable of the trial but informed and treated the patients in their usual way."

Comment: unclear if the surgeons were aware of which participants had received the individualised teaching session. Since the focus of the trial was on measures of patient knowledge, satisfaction and compliance, this is not an important source of bias.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: no exclusions or withdrawals reported. Sample sizes are not reported in the results tables so not possible to verify if are no missing data.

Selective reporting (reporting bias)Unclear riskComment: all outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Siggeirsdottir 2005

MethodsMulti-site randomised trial.


Participants50 participants (26 women, 24 men; mean age 68 years, range 28 to 86) undergoing total hip replacement. Intervention group: 14 women, 13 men (mean age 69 years, range 52 to 81); control group: 12 women, 11 men (mean age 66 years, range 28 to 86).

Inclusion criteria: participants living in their own home diagnosed with osteoarthritis of the hip, rheumatoid arthritis, primary segmental collapse of the femoral head or sequelae after developmental diseases or hip trauma.

Exclusion criteria: primary hip fracture, metastatic tumours, dementia.

Location: Reykjavik and Akranes, Iceland.


InterventionsIntervention group (n = 27) received a preoperative education and training programme 1 month before surgery given by a physiotherapist or occupational therapist (or both). Participants were informed about rehabilitation, became familiar with exercises and the devices to be used postoperatively. Participants also received an illustrated brochure on how to exercise postoperatively. Following discharge, participants received regular home visits from an outpatient team.

Control group (n = 23) was treated according to clinical procedures already in use.


OutcomesFunction* (Oxford Hip Score (12-60 points) higher score represented more dysfunction; Harris Hip Score (maximum 100 points) 90-100: good function and excellent results, 80-90: good, 70-80: fair, < 70: poor results; and Nottingham Health Profile (maximum 100 points) higher score represented more dysfunction); length of hospital stay; complications. Participants were assessed preoperatively and 2, 4 and 6 months postoperatively.


Notes*Only outcome data for the Oxford Hip Score was reported in the trial publication, so no outcome data for the Harris Hip Score and Nottingham Health Profile were included in the review. Oxford Hip Score data at 6 months included in Analysis 1.2.

The original trial design was to carry out the trial at one hospital only. The decision to expand to a second site was made for financial reasons, and because of a high initial drop-out. Treatment group was treated differently postoperatively, in that a physiotherapist or occupational therapist visited them at home after discharge. Only data up to discharge were used in the analyses. A cost analysis of the trial was published as a separate paper (Siggeirsdottir 2005).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskComment: sequence generation not described.

Allocation concealment (selection bias)Low riskQuote: "...they were randomized into one of the two groups (SG [study group] or CG [control group]) by opening a sealed envelope containing a note indicating which group the patient was to be allocated."

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: no description of any attempt to blind participants and blinding is unlikely to have been possible. Knowledge of being in the intervention group may have influenced participants' pain and function scores.

Blinding (performance bias and detection bias)
Objective outcomes
Unclear riskComment: not described.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskComment: 2 control group participants missing preoperative pain and function scores. Impact of incomplete data likely to be minimal because outcomes are continuous measures.

Selective reporting (reporting bias)High riskComment: outcome data were not fully reported for the Harris Hip Score or Nottingham Health Profile (trialists only reported P values for the differences between groups rather than means and SDs). Also, without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Sjöling 2003

MethodsRandomised parallel group trial.


Participants60 participants (36 women, 24 men; mean age 71 years, range 54 to 86) undergoing total knee replacement.

Inclusion criteria: diagnosis of osteoarthritis, aged ≥ 50 years.

Exclusion criteria: rheumatoid arthritis, postoperative state of confusion.

Location: Sweden.


InterventionsIntervention (n = 30) and control (n = 30) groups had a 20- to 40-minute private information session with one of the investigators within 4 days of surgery. Information of a procedural nature was given verbally and in a leaflet. Participants were informed of postoperative pain measurements and showed how to use the VAS.

Intervention group received additional specific information (verbally and in a leaflet) that emphasised the participant's role in pain management and explained the benefits of well-treated postoperative pain for improving recovery and reducing complications.


OutcomesPain (VAS with scores ranging from 0 to 10 where a higher score represented worse pain, postoperative analgesics); satisfaction with pain management and nursing care; state and trait anxiety (5-point Likert scale where a higher score represented greater anxiety); length of hospital stay. Participants were assessed preoperatively and 1, 2 and 3 days postoperatively.


NotesTrialists reported that "The mean length of hospitalisation was 11 days and it was the same for both groups". Attempts to retrieve missing SDs were unsuccessful.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskQuote: "... the first patient was randomised to the treatment group and each subsequent following patient was altered (sic) allocated to either group."

Comment: alternation is not a random method of generating a sequence.

Allocation concealment (selection bias)High riskComment: unlikely that allocation was concealed using alternation.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: no description of any attempt to blind participants and blinding is unlikely to have been possible. Knowledge of being in the intervention group may have influenced participants' pain measurements and satisfaction with care.

Blinding (performance bias and detection bias)
Objective outcomes
Unclear riskQuote: staff were aware that patients were taking part in a trial but "They were not informed that the patients were divided into two groups and participating in an intervention trial."

Comment: staff assessed pain by getting participants to indicate their pain on the VAS and so it is possible that staff could have discovered which group a participant was in. The impact on the objective outcomes of staff being aware of group allocation is likely to be minor.

Incomplete outcome data (attrition bias)
All outcomes
Low riskQuote: "All the patients with postoperative patient controlled analgesia (PCA), two in the treatment group and one in the control group, were excluded from the analysis of analgesic use postoperatively due to their markedly higher use of opioids, leading to disturbances in the data."

Comment: the number of participants excluded from the analyses and the reasons why are described in full.

Selective reporting (reporting bias)High riskComment: all outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results. Outcome data were only reported as medians and IQRs, so data were unable to be included in meta-analyses.

Other biasLow riskComment: no other sources of bias identified.

Vukomanović 2008

MethodsRandomised parallel group trial.


Participants45 participants undergoing total hip replacement. Intervention group: 14 women, 9 men (mean age 60 years, SD 11, range 30 to 70); control group: 16 women, 6 men (mean age 56 years, SD 18, range 19 to 70).

Inclusion criteria: primary or secondary osteoarthritis, aged ≤ 70 years, ability to walk and climb stairs unaided.

Exclusion criteria: none stated (see Notes).

Location: Serbia.


InterventionsIntervention group (n = 23) were given a brochure and received intensive preoperative preparation from a physician (1 appointment) and physiotherapist (2 practical classes). The education covered the surgery and rehabilitation, including instruction in performing exercises and activities from the postoperative rehabilitation programme (e.g. getting out of bed, walking with crutches, etc.).

Control group (n = 22) did not receive preoperative education or physiotherapy.


OutcomesPain (VAS (0-100 points) higher score represented worse pain); range of motion; functional status (Harris Hip Score (maximum 100 points) 90-100: good function and excellent results, 80-90: good, 70-80: fair, < 70: poor results; hip score of the Japanese Orthopaedic Association (JOA) (0-80 points) higher score represented less dysfunction; and Oxford Hip Score (12-60 points) higher score represented more dysfunction*); ability to perform 9 activities of daily living; length of hospital stay; days to stand or walk. Participants were assessed preoperatively, at discharge and 15 months postoperatively (Oxford Hip Score).


Notes*Oxford Hip Score data at 15 months included in Analysis 1.2, as this was the latest time point available in the trial report.

No pre-trial exclusion criteria stated but reasons for exclusion during the trial included intraoperative fracture or postoperative complications that compromised or delayed start of physiotherapy.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The patients were randomly divided into two groups."

Comment: sequence generation not described.

Allocation concealment (selection bias)Unclear riskComment: allocation concealment not described.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: no description of any attempt to blind participants and blinding is unlikely to have been possible. Staff assessed functional status and evaluated the participant's ability to perform 9 basic activities but there is no description of whether any of the trial personnel or staff were blinded. Knowledge of being in the intevention group may have influenced participants' assessments of pain and functional status.

Blinding (performance bias and detection bias)
Objective outcomes
Unclear riskComment: no description of blinding of trial personnel; length of stay could have been influenced by awareness of a participant's assignment.

Incomplete outcome data (attrition bias)
All outcomes
Low riskComment: 5 participants were excluded postoperatively (3 from intervention group, 2 from control group) due to complications during or following surgery. 4 participants were lost to follow-up at 15 months (2 in each group). Impact of incomplete data likely to be minimal because outcomes are all continuous measures.

Selective reporting (reporting bias)Unclear riskComment: all outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

Wijgman 1994

MethodsRandomised parallel group trial.


Participants64 participants undergoing total hip replacement (48 women, 16 men; mean age 65 years, range 42 to 85).

Inclusion criteria: primary coxarthrosis confirmed by X-ray.

Exclusion criteria: pathological malformations (other than hip problems) that could interfere with rehabilitation.

Location: Maastricht, Netherlands.


InterventionsIntervention group (n = 31) received preoperative instructions (30 minutes) in groups of 4-6 delivered by 2 physiotherapists as well as preoperative exercise therapy including muscle-setting exercises.

Control group (n = 33) not described.


OutcomesDays to mobilisation (standing, walking and climbing stairs); length of hospital stay; pain (medication). Participants were assessed preoperatively and 7, 10 and 14 days postoperatively.


NotesPublication is written in Dutch and was translated into English.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskQuote: "The patients... were divided at random..."

Comment: sequence generation not described.

Allocation concealment (selection bias)Unclear riskComment: method of allocation not described.

Blinding (performance bias and detection bias)
Self-reported outcomes
High riskComment: no description of any attempt to blind participants and blinding is unlikely to have been possible.

Blinding (performance bias and detection bias)
Objective outcomes
Unclear riskComment: no description of blinding of trial personnel; mobilisation and length of stay could have been influenced by awareness of a participant's assignment.

Incomplete outcome data (attrition bias)
All outcomes
Low riskAdequate description of withdrawals.

Selective reporting (reporting bias)Unclear riskComment: outcome data were only presented as box plots, and attempts to retrieve means and SDs were successful. All outcomes listed in the methods were reported in the results, but without the trial protocol, it is unclear whether any other outcomes were measured but not reported based on the results.

Other biasLow riskComment: no other sources of bias identified.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Berge 2004Examined the effects of a pain management programme that was administered > 6 weeks prior to surgery.

Bondy 1999Studied the effects of anaesthetic patient education on preoperative anxiety. Although the participants were undergoing total hip replacements, the information was not specific to hip or knee replacement surgery.

Brull 2002Not a trial of preoperative education. Anxiety and depression were measured in a randomly selected group of participants undergoing elective hip or knee replacement with the aim of measuring the effects of preoperative anxiety and depression on postoperative recovery.

Ferrara 2008The preoperative intervention included only physiotherapy exercises; advice was delivered postoperatively. No additional education was provided.

Gammon 1996aIn addition to receiving preoperative education, participants in the intervention group were also exposed to a postoperative teaching programme before discharge. The trial was excluded because it was not possible to isolate the effects of the preoperative education.

Gill 2009The trial compared two preoperative exercise-based programmes without a specific educational component. As participants were awaiting surgery at the time of the trial, all outcomes were measured only preoperatively.

Haslam 2001A trial to detect differences between acupuncture and advice/exercise in the symptomatic treatment of osteoarthritis of the hip. Participants were on a waiting list for hip replacement but did not have surgery as part of the trial. Advice given was not related to surgery for hip replacement.

Hough 1991Not a randomised trial.

Mancuso 2008The trial measured changes in patients' expectations of postoperative recovery. No outcomes were measured of relevance to the inclusion criteria of this review.

Mikulaninec 1987Preoperative instruction was of a general nature and not specific to hip or knee replacement. It was designed for people undergoing a range of general surgical procedures including abdominal, thoracic, perineal and orthopaedic surgery.

Nuñez 2006The intervention was delivered to people on the waiting list for knee replacement surgery. No surgery occurred during the trial period, and all outcomes were measured preoperatively.

Pour 2007The intervention and control groups received different postoperative rehabilitation and analgesia. The effects of the preoperative counselling intervention could not be determined.

Roach 1995Not a randomised trial.

Ródenas-Martínez 2008In addition to preoperative education, the intervention group received more frequent postoperative physiotherapy than the control group. From postoperative measurements, the effects of the preoperative education intervention could not be determined.

Wong 1985The intervention combined preoperative instruction of rehabilitation exercises with postoperative behavioural strategies (including an alarm clock reminder to do exercises and verbal reinforcement from nurses).

Yeh 2005A quasi-experimental design was used whereby "all subjects were not randomly assigned". To begin with, 33 participants were recruited to the control group, then a further 33 participants were recruited to the experimental group.

 
Characteristics of studies awaiting assessment [ordered by study ID]
Eschalier 2012

MethodsRandomised trial.

Participants44 participants undergoing total knee replacement.

InterventionsEducation booklet (n = 22) versus usually delivered information (n = 22).

OutcomesPatient knowledge and beliefs (scores at inclusion to the trial, day before surgery and 6 weeks after surgery). Satisfaction score at final evaluation.

NotesStudy conducted in France. Reported as conference abstract.

Huang 2012

MethodsRandomised trial.

Participants243 participants undergoing total knee replacement.

InterventionsPreoperative rehabilitation education programme started 2-4 weeks before admission (n = 126) versus standard rehabilitation programme (n = 117).

OutcomesFunctional recovery, pain tolerance, length of stay, medical cost and post-surgery complications.

NotesStudy conducted in Taiwan.

Wilson 2012

MethodsRandomised trial.

Participants143 participants undergoing total knee arthroplasty.

InterventionsIndividually delivered preoperative educational intervention (n = 73) versus usual care (n = 70).

OutcomesPrimary: pain-related interference with activity.

Secondary: pain, nausea, expected postoperative activity, analgesic and antiemetic in early postoperative period.

NotesStudy conducted in Ontario, Canada. PhD thesis.

 
Characteristics of ongoing studies [ordered by study ID]
Riddle 2012

Trial name or titleKASTPain Trial.

Methods3-arm randomised trial.

ParticipantsPeople scheduled for total knee arthroplasty.

InterventionsGroup 1: 8 x 1-hour sessions of 1-to-1 instruction delivered over a 2-month period beginning about 2 weeks before surgery.

Group 2: arthritis education sessions.

Group 3: usual care.

OutcomesPrimary: function-related pain.

Secondary: self reported function, pain, global rating, walk test and physical performance. Cost measures: employment status, healthcare visits, inpatient admissions.

Starting dateUnknown.

Contact informationDaniel L Riddle: dlriddle@vcu.edu.

Departments of Physical Therapy and Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA.

NotesStudy conducted in 4 sites in US (Virginia, Illinois and North Carolina).

 
Comparison 1. Preoperative education for hip replacement versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain3Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Hip (up to 3 months)
3227Std. Mean Difference (IV, Random, 95% CI)-0.17 [-0.47, 0.13]

 2 Function4Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Hip (3 to 24 months)
4177Std. Mean Difference (IV, Random, 95% CI)-0.44 [-0.93, 0.06]

 3 Postoperative anxiety (Spielberger State-Trait Anxiety Index)3Mean Difference (IV, Random, 95% CI)Subtotals only

    3.1 Hip (up to 6 weeks postoperatively)
3264Mean Difference (IV, Random, 95% CI)-2.28 [-5.68, 1.12]

 4 Total number of serious adverse events2Risk Ratio (M-H, Random, 95% CI)Subtotals only

    4.1 Hip (any serious postoperative complications)
2150Risk Ratio (M-H, Random, 95% CI)0.79 [0.19, 3.21]

 5 Preoperative anxiety (Spielberger State-Trait Anxiety Index)4Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 Hip
4333Mean Difference (IV, Random, 95% CI)-5.10 [-7.17, -3.03]

 6 Length of hospital stay (days)7Mean Difference (IV, Random, 95% CI)Subtotals only

    6.1 Hip
7487Mean Difference (IV, Random, 95% CI)-0.79 [-1.96, 0.37]

 7 Mobility (days to standing or walking)6Mean Difference (IV, Random, 95% CI)Subtotals only

    7.1 Hip
6417Mean Difference (IV, Random, 95% CI)-0.12 [-0.30, 0.07]

 8 Range of motion (degrees)2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    8.1 Hip abduction (up to 6 weeks postoperatively)
295Mean Difference (IV, Fixed, 95% CI)-1.09 [-5.35, 3.17]

    8.2 Flexion of the hip with flexed knee (up to 6 weeks postoperatively)
136Mean Difference (IV, Fixed, 95% CI)0.75 [-7.67, 9.17]

    8.3 Flexion of the hip with extended knee (up to 6 weeks postoperatively)
136Mean Difference (IV, Fixed, 95% CI)-0.25 [-9.17, 8.67]

 9 Sensitivity analysis: pain1Mean Difference (IV, Random, 95% CI)Subtotals only

    9.1 Hip (up to 6 weeks postoperatively)
1100Mean Difference (IV, Random, 95% CI)-7.0 [-14.85, 0.85]

 10 Sensitivity analysis: function1Mean Difference (IV, Random, 95% CI)Subtotals only

    10.1 Hip (6 months postoperatively)
147Mean Difference (IV, Random, 95% CI)-7.0 [-10.55, -3.45]

 
Comparison 2. Preoperative education for knee replacement versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain2Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Knee (2 days postoperatively)
126Mean Difference (IV, Random, 95% CI)-12.20 [-29.77, 5.37]

    1.2 Knee (12 months postoperatively)
1109Mean Difference (IV, Random, 95% CI)2.0 [-3.45, 7.45]

 2 Function1Mean Difference (IV, Random, 95% CI)Subtotals only

    2.1 Knee (12 months postoperatively)
1109Mean Difference (IV, Random, 95% CI)0.0 [-5.63, 5.63]

 3 Health-related quality of life1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    3.1 SF-36 Physical Component Score (12 months postoperatively)
1109Mean Difference (IV, Fixed, 95% CI)-3.0 [-6.38, 0.38]

    3.2 SF-36 Mental Component Score (12 months postoperatively)
1109Mean Difference (IV, Fixed, 95% CI)-2.0 [-5.06, 1.06]

 4 Total number of serious adverse events1Risk Ratio (M-H, Random, 95% CI)Subtotals only

    4.1 Knee (deep vein thrombosis)
1115Risk Ratio (M-H, Random, 95% CI)0.55 [0.14, 2.08]

    4.2 Knee (pulmonary emboli)
1115Risk Ratio (M-H, Random, 95% CI)1.09 [0.16, 7.48]

    4.3 Knee (infection)
1115Risk Ratio (M-H, Random, 95% CI)0.73 [0.13, 4.19]

    4.4 Knee (any serious postoperative complications)
1115Risk Ratio (M-H, Random, 95% CI)0.69 [0.29, 1.66]

 5 Preoperative anxiety (Spielberger State-Trait Anxiety Index)1Mean Difference (IV, Random, 95% CI)Subtotals only

    5.1 Knee
168Mean Difference (IV, Random, 95% CI)-5.52 [-8.34, -2.70]

 6 Length of hospital stay (days)2Mean Difference (IV, Random, 95% CI)Subtotals only

    6.1 Knee
2183Mean Difference (IV, Random, 95% CI)-1.86 [-3.40, -0.32]

 7 Mobility (days to standing or walking)1Mean Difference (IV, Random, 95% CI)Subtotals only

    7.1 Knee
168Mean Difference (IV, Random, 95% CI)-1.13 [-2.82, 0.56]

 8 Range of motion (degrees)1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    8.1 Knee flexion and extension (i.e. total range of sagittal knee motion) (12 months postoperatively)
1109Mean Difference (IV, Fixed, 95% CI)-4.0 [-10.02, 2.02]

 9 Sensitivity analysis: pain1Mean Difference (IV, Random, 95% CI)Subtotals only

    9.1 Knee (12 months postoperatively)
1109Mean Difference (IV, Random, 95% CI)2.0 [-3.45, 7.45]

 10 Sensitivity analysis: function1Mean Difference (IV, Random, 95% CI)Subtotals only

    10.1 Knee (12 months postoperatively)
1109Mean Difference (IV, Random, 95% CI)0.0 [-5.63, 5.63]

 
Summary of findings for the main comparison. Preoperative education versus usual care for hip replacement

Preoperative education versus usual care for hip replacement

Patient or population: hip replacement
Settings: inpatient and outpatient
Intervention: preoperative education versus usual care

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlPreoperative education versus usual care

Pain
Visual analogue scale. Scale from: 0 to 10 (lower scores indicate less pain).
Follow-up: up to 3 months
The mean pain in the control groups was
3.11
The mean pain in the intervention groups was
0.34 lower
(0.94 lower to 0.26 higher)2
-227
(3 studies)
⊕⊝⊝⊝
low3,4
Absolute risk difference -3% (95% CI -9% to 3%); relative per cent change -11% (95% CI -30% to 8%).

NNTB NA

SMD -0.17 (95% CI -0.47 to 0.13)

Function
WOMAC function (Likert scale version). Scale from: 0 to 68 (lower scores indicate better function).
Follow-up: from 3 to 24 months
The mean function in the control groups was
18.45
The mean function in the intervention groups was
4.84 lower
(10.23 lower to 0.66 higher)6
-177
(4 studies)
⊕⊝⊝⊝
low3,4
Absolute risk difference -7% (95% CI -15% to 1%); relative per cent change -26% (95% CI -56% to 4%).

NNTB NA

SMD -0.44 (95% CI -0.93 to 0.06).

Health-related quality of lifeSee commentSee commentNot estimable-See comment2 trials reported measuring health-related quality of life using the Nottingham Health Profile, but neither reported data suitable for analysis.

Global assessment of treatment successSee commentSee commentNot estimable-See commentNo trial reported measuring global assessment of treatment success.

Postoperative anxiety
Spielberger State-Trait Anxiety Index. Scale from: 20 to 80 (lower scores indicated less anxiety).
Follow-up: mean 6 weeks
The mean postoperative anxiety in the control groups was
32.167
The mean postoperative anxiety in the intervention groups was
2.28 lower
(5.68 lower to 1.12 higher)
-264
(3 studies)
⊕⊕⊝⊝
low4,8
Absolute risk difference -4% (95% CI -10% to 2%); relative per cent change -7% (95% CI -18% to 4%).

Total number of serious adverse events (infection, thrombosis, other serious adverse events)Study populationRR 0.79 (95% CI 0.19 to 3.21)150 (2 studies)⊕⊝⊝⊝
very low3,4,9
Absolute risk difference -10% fewer adverse events with preoperative education (-46% fewer to 27% more); relative per cent change -21% (95% CI -81% to 221%).

227 per 1000179 per 1000
(43 to 728)

Re-operation rateSee commentSee commentNot estimable-See commentNo trial reported measuring re-operation rate.

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; NA: not available; NNTB: number needed to treat for an additional beneficial outcome; RR: risk ratio; SMD: standardised mean difference; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Mean visual analogue scale (VAS) (0-10) pain score at 3 months in the usual care group reported in McGregor 2004 was used as the assumed control group risk.
2 To convert SMD to mean difference (MD), the pooled baseline standard deviation (SD) in McGregor 2004 (SD = 2) was multiplied by the SMDs and 95% CIs to convert values to a 0- to 10-point VAS.
3 In all but 1 randomised controlled trial, allocation concealment was unclear, and no trial blinded participants.
4 95% CIs of the MD are wide.
5 Mean WOMAC function score at 3 months in the usual care group reported in McGregor 2004 was used as the assumed control group risk.
6 To convert SMD to MD, the pooled baseline SD in McGregor 2004 (SD = 11) was multiplied by the SMDs and 95% CIs to convert values to the 0- to 68-point WOMAC function (Likert scale version) score.
7 Control group mean calculated as the mean of Butler 1996 and Doering 2000 (which both reported end of treatment values; Giraudet 2003 was excluded from this estimation as only change scores were reported).
8 Only 1 of the 3 included RCTs had unclear allocation concealment (the remaining 2 RCTs had clear allocation concealment), though no RCT blinded participants.
9 Heterogeneity was very high (I2 = 85%).
 
Summary of findings 2. Preoperative education versus usual care for knee replacement

Preoperative education versus usual care for knee replacement

Patient or population: people with knee replacement
Settings: inpatient and outpatient
Intervention: preoperative education versus usual care

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlPreoperative education versus usual care

Pain
WOMAC pain. Scale from: 0 to 100 (lower scores indicate less pain).
Follow-up: mean 12 months
The mean pain in the control groups was
80
The mean pain in the intervention groups was
2 higher
(3.45 lower to 7.45 higher)
-109
(1 study)
⊕⊕⊝⊝
low1,2
Absolute risk difference 2% (95% CI -4% to 8%); relative per cent change 2.5% (95% CI -4% to 9%).

Function
WOMAC function. Scale from: 0 to 100 (lower scores indicate better function).
Follow-up: mean 12 months
The mean function in the control groups was
77
The mean function in the intervention groups was
0 higher
(5.63 lower to 5.63 higher)
-109
(1 study)
⊕⊕⊝⊝
low1,2
Absolute risk difference 0% (95% CI -6% to 6%); relative per cent change 0% (95% CI -7% to 7%).

Health-related quality of life
SF-36 Physical Component Score. Scale from: 0 to 100 (higher scores indicate better quality of life).
Follow-up: mean 12 months
The mean health-related quality of life in the control groups was
41
The mean health-related quality of life in the intervention groups was
3 lower
(6.38 lower to 0.38 higher)
-109
(1 study)
⊕⊕⊝⊝
low1,2
Absolute risk difference -3% (95% CI -6% to 1%); relative per cent change -7% (95% CI -16% to 1%).

Global assessment of treatment successSee commentSee commentNot estimable-See commentNo trial reported measuring global assessment of treatment success.

Postoperative anxietySee commentSee commentNot estimable-See commentNo trial reported measuring postoperative anxiety.

Total number of serious adverse events (infection, thrombosis, other serious adverse eventsStudy populationRR 0.69 (0.29 to 1.66)115 (1 study)⊕⊕⊕⊝
low1,2
Absolute risk difference -6% (95% CI -19% to 8%); relative per cent change -31% (95% CI -71% to 66%).

183 per 1000127 per 1000
(53 to 304)

Re-operation rateSee commentSee commentNot estimable-See commentNo trial reported measuring re-operation rate.

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio; SF-36: 36-item Short Form; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Participants were not blind to treatment.
2 95% CIs are wide and include the null value.
 
Table 1. Description of the education intervention

Trial IDContent

Beaupre 2004Participants in the treatment group underwent a 4-week exercise/education programme before surgery. The education programme consisted of instruction regarding crutch walking, bed mobility and the postoperative range of motion routine. The exercise programme was designed to improve knee mobility and strength using simple exercises with progressive resistance. The subjects were asked to attend the treatment programme three times a week for four weeks.

Butler 1996An 18-page teaching booklet 'Total hip replacement: a patient guide' was sent to participants at home. The booklet was developed by a multidisciplinary team and contained: information on the anatomy of a normal and diseased hip; total hip prosthesis; exercises to practice before admission; what to expect in hospital; precautions following surgery and planning for discharge. The booklet had a readability age of Grade 6 to 7 with 22 drawings and photographs.

Clode-Baker 1997A 20-minute video, booklet and set of plastic models were sent to participants at home. The video followed the progress of a person undergoing hip replacement surgery, from difficulties encountered at home through to the hospital stay, postoperative recovery and exercises. The booklet addressed similar issues and included advice from previous participants. The booklet described arthritis and backed up information presented in the video. The life-size plastic model bones demonstrated changes of the total hip replacement by comparison with a normal hip joint, osteoarthritis and an implanted total hip replacement prosthesis.

Cooil 1997An information sheet that was already in clinical use was made available at the participants' bedside. The sheet contained instructions on the postoperative protocol, exercises and advice on beneficial and harmful postoperative activities. In addition, a verbal explanation of the sheet's contents was given, and the exercises and activities were taught through demonstration and practiced under supervision.

Crowe 2003A preoperative education package consisting of a 50-minute video and a booklet giving information on length of hospital stay, discharge criteria, respite care and diet was provided to participants the first time they visited the clinic following randomisation. The video focused on the participant's responsibility during the postoperative phase and use of equipment. Some participants were given a tour of the hospital unit, demonstration of equipment, dietician counselling and social work input. All participants received extensive individualised counselling from an occupational therapist on all aspects of optimising function and independence postoperatively, including home assessments, and were provided with a telephone contact for additional information. A physical conditioning programme was available to participants to improve strength and endurance and facilitate postoperative mobility. Participants also received the same standard preoperative clinic visit as the control participants.

Daltroy 1998A 12-minute audiotape slide programme was presented by a research assistant at the bedside the day before surgery. The audiotape oriented the participant to the hospital, staff, surgery and rehabilitation. Participants were told of various stressful aspects of their hospital stay, and reassured that these were normal. The tape complemented the standard preoperative information. The comparison group received relaxation training consisting of oral and written instructions and an 18-minute audiotape.

Doering 2000A 12-minute video shown in hospital preoperatively in the presence of the investigator. The video followed a person with osteoarthritis undergoing hip replacement. Filmed from the person's perspective, the video showed what to expect from hospital, the procedure, the recovery and rehabilitation. It included original dialogue, a narrator giving procedural information and interviews with the person.

Giraudet 2003Participants in the multidisciplinary collective information group (trial group) received verbal information and a standard information leaflet. They also attended an education session 2 to 6 weeks before surgery, where a multidisciplinary team including a surgeon and an anaesthetist presented a standardised education programme. The team discussed the intervention and answered the questions of patients and their significant others. The control group received only the usual verbal information from the surgeon and the anaesthetist and the standard information leaflet.

Gocen 2004Participants in the trial group received preoperative physiotherapy to strengthen and improve range of motion of the hip, beginning from eight weeks before the operation. These participants also received an educational programme that included advice on movements that should be avoided, use of assistance devices, posture, lifting and carrying, washing and bathing. The control group received no preoperative physiotherapy or educational programme.

Johansson 2007Standard written education materials plus education using the concept map method. The education was delivered by two specially trained nurses two weeks before admission and lasted approximately 30 to 60 minutes. The concept map method involved counselling in relation to biophysiological, functional, experiential, ethical, social and financial issues about pre and postoperative care.

Lilja 1998In addition to being informed by ward nurses about preoperative routines and what to expect before and after the operation, participants spent 30 minutes with an anaesthetic nurse. The information provided by the nurse covered the importance of preoperative preparation and patient participation in recovery, the operating theatre and mobilisation following surgery.

McDonald 2004Participants were randomly assigned to one of three groups. In the preoperative period, the communication group (treatment group) viewed a 4-minute pain communication film as well as a 10-minute pain management film. Comparison group 1 viewed only the pain management film, and comparison group 2 received standard care only. Handouts reinforcing the main content of both films were distributed to the communication group. Comparison group 1 received only the pain management handout.

McGregor 2004Participants in the treatment group received a preoperative hip class 2 to 4 weeks before surgery and an information booklet. The information booklet documented information on the surgery, rehabilitation stages including exercise regimens, and answers to commonly asked questions. The preoperative class enforced the booklet and ensured that all participants could do the exercises, understood how to use walking aids postoperatively, and could adapt their homes for the recovery period. The control group received the standard preoperative treatment, which included a description of the surgery and its risks and approximations on length of hospital stay.

Santavirta 1994Before admission, participants received an 18-page guide on hip replacement surgery and postoperative rehabilitation. They also received a 20- to 60-minute teaching session by the investigator, which was planned according to each participant's situation. Elements covered included safe walking, active exercises, wound care, temperature taking, rehabilitation and discharge planning.

Siggeirsdottir 2005Participants in the trial group participated in a preoperative education and training programme, given by a physiotherapist or an occupational therapist (or both), about one month before the planned operation. The programme covered postoperative rehabilitation, exercises and postoperative assistive devices. Participants also received an illustrated brochure containing information on how to move and exercise postoperatively. When a trial group participant was discharged, a physiotherapist or occupational therapist could accompany the person home and return for follow-up home visits if this was considered necessary. Control group participants were treated according to the clinical procedures already in use and were discharged when rehabilitated, or could be transferred to another rehabilitation facility.

Sjöling 2003Participants received specific information (verbally and in a leaflet) which emphasised the person's own role in pain management by trying to improve knowledge in areas important for their well-being. The specific information covered issues such as people taking an active role in their treatment; postoperative pain and pain management; and the importance of physiotherapy. 

Vukomanović 2008Participants received short-term intensive preoperative preparation consisting of education and elements of physiotherapy. They were informed about the operation, caution measures and rehabilitation following the operation through conversation with the clinician and a brochure. They were instructed by a physiotherapist to perform exercises and basic activities.

Wijgman 1994Participants received preoperative instructions for 30 minutes in groups of 4 to 6 delivered by two physiotherapists. They also received preoperative exercise therapy including muscle setting exercises.

 
Table 2. Outcome Reporting Bias In Trials (ORBIT) outcome matrix

Study IDMajor outcomesMinor outcomesOther outcomes



PainFunctionHRQoLGlobal assessmentPostop anxietyAdverse eventsRe-operation ratePreop anxietyLOSMobilityROMKnowledge (recall)

Beaupre 2004FullFullFullUnclearUnclearFullUnclearUnclearFullUnclearFullUnclear

Butler 1996UnclearUnclearUnclearUnclearFullUnclearUnclearFullFullUnclearUnclearUnclear

Clode-Baker 1997PartialUnclearPartialUnclearPartialUnclearUnclearUnclearPartialPartialUnclearUnclear

Cooil 1997UnclearUnclearUnclearUnclearUnclearUnclearUnclearUnclearUnclearUnclearUnclearPartial

Crowe 2003UnclearUnclearUnclearUnclearUnclearUnclearUnclearFullFullFullUnclearUnclear

Daltroy 1998PartialUnclearUnclearUnclearPartialUnclearUnclearUnclearPartialUnclearUnclearUnclear

Doering 2000FullUnclearUnclearUnclearFullUnclearUnclearFullFullFullUnclearUnclear

Giraudet 2003FullUnclearUnclearUnclearFullFullUnclearFullFullFullUnclearUnclear

Gocen 2004PartialFullUnclearUnclearUnclearUnclearUnclearUnclearPartialFullFullUnclear

Johansson 2007UnclearUnclearUnclearUnclearUnclearUnclearUnclearUnclearPartialUnclearUnclearPartial

Lilja 1998PartialUnclearUnclearUnclearPartialUnclearUnclearPartialUnclearUnclearUnclearUnclear

McDonald 2004FullUnclearUnclearUnclearUnclearUnclearUnclearUnclearUnclearUnclearUnclearUnclear

McGregor 2004FullFullUnclearUnclearUnclearPartialUnclearUnclearPartialUnclearUnclearUnclear

Santavirta 1994UnclearUnclearUnclearUnclearUnclearPartialUnclearUnclearUnclearUnclearUnclearPartial

Siggeirsdottir 2005UnclearFullPartialUnclearUnclearFullUnclearUnclearFullUnclearUnclearUnclear

Sjöling 2003PartialUnclearUnclearUnclearPartialUnclearUnclearUnclearPartialUnclearUnclearUnclear

Vukomanović 2008PartialFullUnclearUnclearUnclearUnclearUnclearUnclearFullFullFullUnclear

Wijgman 1994UnclearUnclearUnclearUnclearUnclearUnclearUnclearUnclearFullFullUnclearUnclear

 HRQoL: health-related quality of life; LOS: length of hospital stay; preop: preoperative; postop: postoperative; ROM: range of motion.
'Full' = sufficient data for inclusion in a meta-analysis were reported (e.g. mean, standard deviation, and sample size per group for continuous outcomes).
'Partial' = insufficient data for inclusion in a meta-analysis were reported (e.g. means only, with no measures of variation).
'Unclear' = unclear whether the outcome was measured or not (as a trial protocol was unavailable).
 
Table 3. Results of included studies with data not appropriate for meta-analysis

Trial IDOutcomeResults

Clode-Baker 1997Preoperative anxiety (Hospital Anxiety and Depression Scale 0 to 21)Intervention: median 6 (range 1 to 17).
Control: median 8 (range 2 to 21).
No statistically significant difference between the 2 groups.

Clode-Baker 1997Postoperative anxiety (Hospital Anxiety and Depression Scale 0 to 21)Intervention: median 5 (range 1 to 15).
Control: median 5 (range 1 to 15).
No statistically significant difference between the 2 groups.

Clode-Baker 1997Nottingham Health Profile (postoperative) (0 to 38)Intervention: median 10 (range 1 to 29).
Control: median 9 (range 0 to 19).
No statistically significant difference between the 2 groups.

Clode-Baker 1997Days to mobilisationIntervention: median 2 (range 1 to 6).
Control: median 2 (range 2 to 3).
No statistically significant difference between the 2 groups.

Clode-Baker 1997Length of hospital stayIntervention: median 12 (range 7 to 21).
Control: median 12 (range 7 to 23).
No statistically significant difference between the 2 groups.

Johansson 2007Length of hospital stayIntervention: mean 6.78.
Control: mean 8.18.
Not statistically significant.

Sjöling 2003VAS pain postoperative day 1Intervention: median 4 (IQR 3.3 to 5.7; range 2 to 9.3).
Control: median 4.3 (IQR 2.2 to 6; range 0 to 8.3).
No statistically significant difference between the 2 groups.

Sjöling 2003VAS pain postoperative day 2Intervention: median 3.8 (IQR 2.6 to 5.1; range 1 to 9.3).
Control: median 4.0 (IQR 3.3 to 5; range 0 to 7.3).
No statistically significant difference between the 2 groups.

Sjöling 2003VAS pain postoperative day 3Intervention: median 3.0 (IQR 1.7 to 3.7; range 0 to 7.7).
Control: median 2.3 (IQR 1.7 to 4.2; range 0 to 8.3).
No statistically significant difference between the 2 groups.

Vukomanović 2008VAS pain at dischargeIntervention: mean 3.95, SD 13.08, median 0 (range 0 to 58).
Control: mean 6.2, SD 14.95, median 0 (range 0 to 50).
No statistically significant difference between the 2 groups.

 IQR: interquartile range; VAS: visual analogue scale.