Effectiveness of prehabilitation modalities before total hip arthroplasty: a systematic review and network meta-analysis.

BACKGROUND: Prehabilitation has been proposed to enhance recovery after total hip arthroplasty (THA). Understanding its preoperative effectiveness across modalities is an important step towards clarifying its potential role in optimizing recovery. OBJECTIVE: To compare the preoperative effectiveness of various prehabilitation modalities with standard care on physical function, pain, health-related quality of life (HR-QoL), and Timed Up and Go (TUG) performance in individuals awaiting THA, and to summarize other performance-based, strength, and hip-specific outcomes when data were insufficient for network meta-analysis. METHODS: A systematic review and network meta-analysis of randomized controlled trials (RCTs) was conducted following PRISMA guidelines. Eligible studies included individuals undergoing THA for end-stage osteoarthritis who received any form of preoperative prehabilitation targeting physical, educational, nutritional, or behavioral domains, either alone or in combination. Comparators were standard care or another prehabilitation intervention. Confidence in the evidence was assessed using CINeMA. RESULTS: 21 RCTs involving 1061 participants were included, comprising 10 prehabilitation modalities: lower-extremity strength training, clinic-based multidomain exercise, home-based exercise (with or without protein supplementation), tele-prehabilitation, neuromuscular electrical stimulation, Tai Chi, upper-body high-intensity training, heat-plus-resistance training, and education. Multidomain exercise, lower-extremity strength training, and Tai Chi demonstrated beneficial preoperative effects, whereas no statistically significant effects were observed for the other modalities. Tai Chi improved physical function (SMD = 0.94; 95% CI 0.07-1.80; I2 = 54%) and TUG performance (SMD = 1.50; 95% CI 0.92-2.07; I2 = 0%). Multidomain exercise reduced pain (SMD = 0.54; 95% CI 0.16-0.92; I2 = 52%) and enhanced HR-QoL (SMD = 0.44; 95% CI 0.16-0.71; I2 = 30%). Lower-extremity strength training improved HR-QoL (SMD = 0.49; 95% CI 0.03-0.94; I2 = 30%). Overall confidence was low to very low due to imprecision, and moderate for Tai Chi versus standard care (TUG). CONCLUSION: Tai Chi, multidomain exercise, and lower-extremity strength training showed preoperative benefits, with moderate-to-low confidence in the evidence. Well-powered trials with standardized outcomes are needed to confirm these effects. REGISTRATION: PROSPERO (CRD42024490615).