Title : Prehab should adapt to the person, not the other way around: A qualitative study exploring stakeholder?perceptions?of prehabilitation for total hip and knee arthroplasty
Abstract:
Background: Despite increasing research on prehabilitation interventions for people undergoing Total Hip and Knee arthroplasty (THA/TKA), little is known about its acceptability to consumers and clinicians, or the barriers and enablers to implementation in clinical settings. Most qualitative research has occurred to evaluate existing prehabilitation programs, rather than during the design phase to inform intervention development.
The aim of this qualitative study was to:
1.Explore acceptability of prehabilitation as an intervention for patients awaiting arthroplasty surgery and to the clinicians involved in delivering care.
2.Identify barriers and enablers to prehabilitation uptake and delivery.
3.Investigate consumers and clinicians’ perspectives on an ideal model of prehabilitation care in this setting and identify possible strategies for future implementation.
Methods: Semi-structured interviews were conducted with consumers who had undergone or were awaiting THA/TKA at a quaternary public hospital in Melbourne, Australia, and with clinicians involved in perioperative care for this cohort. Interview guides were informed by the Theoretical Framework of Acceptability (TFA) and the Theoretical Domains Framework (TDF). Data were analysed using the Framework Analysis, incorporating inductive and deductive approaches.
Results: 30 semi-structured interviews were completed at one health service in 2024/2025 with consumers (n=15) and clinicians (n=15). Consumers (n=6 pre-operative, n=9 post-operative) had a mean age of 69 years (SD 8) and an average waitlist time of 527 days [IQR 169-749]. Seven participants were awaiting or had received a TKA, and eight were awaiting or had received a THA. Clinicians were physiotherapists (n=7), surgeons (n=4), anaesthetists (n=3) and a surgical liaison nurse (n=1) with varying years of experience.
Three overarching themes were identified which encompassed multiple sub-themes:
1) Understanding and beliefs of prehabilitation for THA/TKA. Prehabilitation was generally acceptable to both consumers and clinicians and seen to be beneficial, although there was significant variation in the understanding of prehabilitation.
2) Factors influencing prehabilitation implementation. Several barriers and enablers to prehabilitation uptake and delivery were identified by both consumers and clinicians at three levels in the care ecosystem (Figure 1) – interpersonal factors related to the consumer (e.g. Mindset regarding preparing for surgery), factors related to the clinician (e.g. Level of confidence discussing prehabilitation with consumers), and system level factors (e.g. Long waitlists make timing prehabilitation relative to surgery challenging).
3) Ideal model of care. Recommendations for prehabilitation implementation prior to THA/TKA were identified, covering ‘who’, ‘what’, ‘when’ and ‘how’ constructs. Participants emphasised the need for tailored care that considers an individual’s goals and risk profile, ongoing prehabilitation support and information from consent through to surgery, the integration of remote monitoring, and multi-modal delivery that affords flexibility. Ten recommendations made by participants are summarised in Figure 2.
Figure 1: Barriers and enablers to prehabilitation uptake and delivery identified at different levels of the care ecosystem in total hip and knee arthroplasty.
Figure 2: Ten recommendations for implementation of orthopaedic prehabilitation prior to total hip and knee arthroplasty.
Conclusion: This study identified factors that influenced the acceptability of and engagement with prehabilitation at multiple levels of care. The findings will help inform the development of a novel stakeholder-informed, multi-modal model of prehabilitation care for THA/TKA.
