Comparative effectiveness of exercise-based prehabilitation before total knee arthroplasty: a systematic review and network meta-analysis of randomized controlled trials

Exercise-based prehabilitation before total knee arthroplasty (TKA) is widely used, yet the comparative effectiveness of different exercise modalities remains uncertain. This network meta-analysis compared the effectiveness of common exercise-based prehabilitation strategies for patients undergoing TKA. Four databases were searched from inception to 31 January 2026. Randomized controlled trials (RCTs) in adults scheduled for primary TKA were included if they evaluated structured preoperative exercise (at least two sessions) versus usual care control (CON), education, or another exercise modality. Interventions were coded as resistance, neuromuscular, balance, aerobic, or multimodal exercise. Outcomes were pain, knee function, Timed Up and Go (TUG), quadriceps strength, knee flexion range of motion (ROM), and quality of life (QoL), assessed preoperatively and/or postoperatively. Random effects NMA estimated standardized mean differences (SMDs) with 95% confidence intervals (CIs) and SUCRA rankings. Twenty-two RCTs involving 1458 participants were included. Compared with CON, resistance training improved TUG (SMD − 0.58, 95% CI − 1.13 to − 0.02) and quadriceps strength (SMD 0.41, 95% CI 0.16 to 0.67). Multimodal exercise improved knee flexion ROM versus CON (SMD 1.63, 95% CI 0.86 to 2.40), balance training (SMD 1.60, 95% CI 0.74 to 2.46), and resistance training (SMD 1.59, 95% CI 0.81 to 2.38). For pain, neuromuscular training, aerobic exercise, education, and multimodal exercise were superior to CON; neuromuscular training and education reduced pain more than resistance training. No significant differences were observed for knee function or QoL. Prehabilitation effects are outcome specific. Resistance training most consistently improved objective functional reserve, neuromuscular and aerobic approaches were more favorable for pain reduction, and multimodal programmes produced the greatest improvement in knee flexion ROM. Preoperative programmes should be matched to the patient’s dominant limitation. CRD420261325501.