A Role for Prehabilitation by Peer Coaches in Improving TKA Outcomes

    Rehabilitation after knee replacement is an essential part of the recovery process. But what’s the best way to prepare patients before the procedure?

    Researchers at Hospital for Special Surgery (HSS) in New York City sought to answer that question with a pilot study designed to determine if a “prehabilitation” program – counseling by a peer coach who has already had a total knee arthroplasty (TKA) – could empower and inform patients scheduled for the surgery, leading to better outcomes.

    The study results were presented at the 2019 ACR/ARP Annual Meeting.

    “On a national level, up to 30% of patients may have persistent pain after knee replacement surgery for osteoarthritis,” said principal investigator Iris Navarro-Millan, MD, MSPH, a rheumatologist at HSS. “One possible approach to improve outcomes is to optimize muscle strength, physical condition, and mental preparation before surgery. Social cognitive theory posits that self-efficacy, peer or social support, sociocultural factors, and expectations influence goals and outcomes.”

    Senior study author Lisa Mandl, MD, MPH, also a rheumatologist at HSS, noted that “there are successful programs in other areas of medicine, such as diabetes care, in which patient navigators share their experience and knowledge with their peers to help them better manage the disease. The thinking is that having the right mindset could optimize outcomes.”

    For the study, the researchers established focus groups of former patients who had undergone TKA at HSS to obtain information about their thoughts and experiences. The researchers sought to determine if a prehabilitation program with trained peer coaches could be helpful and of interest to future patients scheduled for TKA. They defined a peer coach as a patient who has already undergone TKA and has been trained to provide personalized pre- and post-TKA support.

    The 31 patients in the focus groups ranged in age from 65 to 89 and had undergone TKA at HSS at least 12 months earlier and had a good outcome.

    “We asked patients about their challenges before and after knee replacement, potential barriers to accessing a prehabilitation program, and perspectives on what it might be like working with a peer coach to encourage exercise prior to knee replacement,” Dr. Navarro said.

    The following themes emerged from the focus groups:

    • Many patients with osteoarthritis delayed TKA for many years, often until the pain became very bad.
    • Many were not sure of the best way to prepare for TKA.
    • They appreciated advice from other patients about preparation and recovery, noting that learning about the positive experiences of others often motivated them to have surgery.
    • The concept of peer coaches was well received.
    • A few participants were already informally helping others scheduled for surgery and found it very rewarding.

    The researchers concluded that preparation and expectations for surgery were influenced by patients’ own prior experience TKA – about half of the patients in the focus group had undergone TKA on both knees – as well as by the experience of other patients who had already had the surgery.

    “Patients with high outcome expectations who had undergone a previous knee replacement learned from their first experience and reported feeling motivated to engage in physical activity for muscle strengthening before their second knee replacement,” Dr. Navarro explained. “They expressed that their own experiences made them more informed, self-efficacious, and physically active to prepare for their surgery.”

    Focus group members who had undergone TKA on only 1 knee reported that informally connecting with an individual who had already undergone TKA was important in their decision to go ahead with the procedure, and also in preparing for it. They indicated that working with a peer coach would be beneficial for both preparation and recovery.

    “Our findings suggest that formal peer-to-peer counseling that prepares patients for their first knee replacement surgery may hold promise to improve outcomes,” Dr. Navarro said. “Future studies could focus on the best way to establish such a program.”


    Navarro-Millan I, Young S, Lui G, Frey M, Peterson J, Goodman S, Safford M, Mandl L. The Preparation and Recovery Experience from Total Knee Replacement of Patients with Osteoarthritis: A Qualitative Study (Abstract 2762). Presented at the 2019 ACR/ARP Annual Meeting, November 8-13, Atlanta, Georgia.