The reporting of this systematic review is based on the PRISMA guidelines 16. The protocol for this systematic review was registered prospectively with PROSPERO (ID number: 122684).
Eligibility criteria included randomised controlled trials in people, older than 18 years of age with persistent knee pain more than 3 months after a primary total knee replacement. Studies were limited to the English language.
Rehabilitation programs could include one or all of the following in a single or comprehensive program including training, exercises, compensatory strategies, education, support, counselling, mind-body and cognitive strategies, self-management, modifications to the environment and provision of resources and assistive technology. Whilst there is no set definition of rehabilitation, this is in keeping with a modern understanding17, 18. To be eligible, the program needed to be primarily designed to improve knee pain in people with chronic knee pain after a total knee replacement. The therapy could be delivered via an information booklet, in person, via an electronic device (phone, computer or tablet), be group-based or individualised, in a hospital or rehabilitation facility as an inpatient or outpatient, in a private clinic or home-based.
Exclusion criteria included surgery, procedural techniques and injections. The use of medication, TENS, acupuncture, “natural” or complementary therapies and cryotherapy were only permitted if used within a rehabilitation therapy program but not if used individually.
The primary outcome was chronic knee pain defined as any description of pain persisting in the knee region for greater than 3 months following a total knee replacement and reported using a standardised measure of pain such as a patient-reported outcome measure or a visual analogue scale. This includes people with chronic post-surgical pain as defined by the ICD-11 which describes pain as “developing or increasing in intensity after a surgical procedure” 19.
Secondary outcomes were function and quality of life assessed using a standardised patient-reported outcome measure or visual analogue scale.
A search of the following electronic databases was performed: Ovid Medline (1946–12 July, 2020), Embase via Ovid (1974–12 July, 2020), CINAHL Plus (to 12 July, 2020), PsycINFO (1806–12 July, 2020), Ovid Emcare (1995–12 July, 2020) and Proquest. A comprehensive strategy was used (see appendix A, B and C below). A search of referenced articles of identified literature meeting the eligibility criteria was also conducted. Contact was made with one author to clarify the use of a pain scale 20.
The abstracts were downloaded to Endnote and titles and abstracts were screened by NAJ assessing for eligibility criteria. The full text of potentially eligible articles was then assessed by 2 independent reviewers (NAJ, BT) using a standardised approach with the software program Covidence (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org). Any disagreement concerning eligibility was discussed between NAJ and BT with a plan for a third reviewer (KF) to make the final decision if necessary.
Risk of bias in eligible papers was to be assessed using the Cochrane Collaboration guidelines21 and the software Covidence. The Covidence tool assesses 7 domains which include sequence generation, allocation concealment, blinding of participants and personnel for All outcomes, blinding of outcome assessors for All outcomes, incomplete outcome data for all outcomes, selective outcome reporting and other sources of bias. This uses descriptors such as low risk, high risk or unclear risk.
At the protocol stage, the plan for data extraction was to use Covidence with data items to include study source, study methods, participant characteristics, interventions used, outcome assessments and timing of outcomes, results and funding sources.
At the protocol stage, a meta-analysis was planned if 2 or more studies were found with outcome measures assessing pain. The data was to be exported from Covidence to Review Manager 5 ((RevMan) [Computer program], Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) by NJ. Aggregate participant data was to be used to calculate the effect size of the rehabilitation interventions to reduce pain, improve function and quality of life and would include an assessment of heterogeneity. As the number of eligible studies was likely to be small, a narrative descriptive synthesis was thought to be required.