Evidence Based TKR Rehab

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Eur J Phys Rehabil Med. Author manuscript; available in PMC 2014 August 13.
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Eur J Phys Rehabil Med. 2013 December ; 49(6): 877892.
PHYSICAL EXERCISE AFTER KNEE ARTHROPLASTY: A

SYSTEMATIC REVIEW OF CONTROLLED TRIALS
F. Pozzi1, L. Snyder-Mackler1, and J. Zeni1
1Department of Physical Therapy, University of Delaware, Newark, DE, USA
Abstract
Total knee arthroplasty (TKA) is the gold standard treatment for end-stage knee osteoarthritis.
Most patients report successful long-term outcomes and reduced pain after TKA, but recovery is
variable and the majority of patients continue to demonstrate lower extremity muscle weakness
and functional deficits compared to age-matched control subjects. Given the potential positive
influence of post-operative rehabilitation and the lack of established standards for prescribing
exercise paradigms after TKA, the purpose of this study was to systematically review randomized,
controlled studies to determine the effectiveness of post-operative outpatient care on short- and
long-term functional recovery. Nineteen studies were identified as highly relevant for the review
and four categories of post-operative intervention were discussed 1) Strengthening Exercises, 2)
Aquatic Therapy, 3) Balance Training, and 4) Clinical Environment. Optimal outpatient physical
therapy protocols should include: strengthening and intensive functional exercises given through
land-based or aquatic programs, the intensity of which is increased based on patient progress. Due
to the highly individualized characteristics of these types of exercises, outpatient physical therapy
performed in a clinic under the supervision of a trained physical therapist may provide the best
long-term outcomes after the surgery. Supervised or remotely supervised therapy may be effective
at reducing some of the impairments following TKA, but several studies without direct oversight
produced poor results. Most studies did not accurately describe the usual care or control groups
and information about the dose, frequency, intensity and duration of the rehabilitation protocols
were lacking from several studies.
Keywords
Replacement; Exercise Therapy; Physical Therapy Modalities; Rehabilitation
Introduction
Total knee arthroplasty (TKA) is the gold standard treatment for end-stage knee
osteoarthritis (OA) and the annual worldwide incidence of TKA has steadily increased over
the past decade.1-3 Data from 21 European countries revealed that the annual incidence of
Corresponding author: Joseph Zeni, Jr. PT, PhD, Department of Physical Therapy, University of Delaware, 301 McKinly Laboratory,
Newark, DE 19716, USA, [email protected].
Congresses: None
Conflicts of Interest: The authors have no conflicts of interest to report.
Pozzi et al. Page 2
TKA is 109 TKA procedures per 100000 persons, which is more than twice that reported in
1998.4 TKA reliably reduces the pain associated with end-stage knee OA and 90% of
patients report reduced pain, improved functional ability, and greater health related quality
of life after surgery.5 Moreover, 85% of patients who undergo TKA report being satisfied
with the outcomes.5
Despite the well documented success of this procedure, patients after TKA continue to
demonstrate functional, strength and mobility deficits after TKA. One year after surgery,
women take nearly twice as long to ascend and descend a flight of stairs and are 30%
weaker than women without knee pathology.6 These differences are even larger for men.6
Although TKA improves self-reported functional ability and reduces pain, it does not
eliminate all impairments when compared to age-matched individuals without knee
pathology. These residual impairments may also increase the aggregate socio-economic
burden of the disease as the demographics of this population shift to a younger working
age.7,8
Short- and long-term outcomes after TKA may be related to the type and intensity of post-
operative rehabilitation the patients receive, although evidence supporting this relationship
has been sparse. In 2003, the National Institute of Health convened a consensus
development conference to compile the scientific evidence surrounding TKA to enhance
guidelines for clinical decision making and patient clinical outcomes. One of the primary
conclusions from this consensus conference was that the use of rehabilitation services was
one of the most understudied aspects of the perioperative management of patients following
total knee replacement and there is no evidence supporting the generalized use of any
specific preoperative or postoperative rehabilitation interventions.5
Persistent functional deficits and muscle impairments after TKA may be partially attributed
to ineffective or absent post-operative rehabilitation and exercise programs. Currently, there
is no universally accepted rehabilitation protocol for patients after TKA and rehabilitation
paradigms are often institution- or surgeon-specific. A recent analysis of standard post-
operative care revealed that only 26% of patients receive outpatient physical therapy after
being discharged from the hospital.9 This is disconcerting given that recent evidence has
suggested that the type of postoperative rehabilitation influences short- and long-term
functional outcomes.10-12
Given the potential positive influence of post-operative rehabilitation and the lack of
established standards for prescribing exercise paradigms after TKA, the purpose of this
study was to systematically review randomized, controlled studies to determine the
effectiveness of post-operative outpatient care on short- and long-term functional recovery.
This review specifically intended to answer the following questions: 1) What are the most
effective components of outpatient rehabilitation after TKA, and 2) What is the optimal
setting to deliver outpatient physical therapy?
Pozzi et al. Page 3
Methods
Search strategy
Five computer databases (Medline, Embase, Cinahl, Cochrane Library, and Pedro) were
searched for pertinent articles that were published or available online between January 1,
2003 and June 13, 2013. Database specific search strategies were performed using heading
mapping (Appendix 1). Each search included terms such as exercise, physical therapy,
physiotherapy, rehabilitation, knee, knee arthroplasty. The results of each search were first
imported to a computer-based reference software (EndnoteX, Thomson Reuters) to screen
for duplicate studies. Two independent reviewers screened each title and abstract to
determine whether the study was eligible for further review. If the two reviewers agreed
about the inclusion of a study, the study was included in the next step of review. If the two
reviewers disagreed about the inclusion of a study, a third reviewer made the final decision
regarding the inclusion/exclusion of the study.
Selection criteria
Publications were eligible if they: 1) examined the postoperative effects of an exercise-based
intervention in a non-acute care setting; 2) included pain, physical function, self-reported
functional ability, range of motion and/or performance-based test as outcome measures; 3)

included participants who underwent unilateral TKA; 4) included a randomized design
comparing an exercise-based intervention with a comparative group; and 5) the full report
was published in English. An exercise-based intervention was operationally defined using
the definition proposed by Gill&McBurney:13 an intervention that involved participants
completing more than one session of physical exercises such as strengthening, flexibility,
and/or aerobic activities. Studies that assessed the use of continuous passive motion or
compared supervised home therapy versus unsupervised home therapy were excluded from
this review. Studies that were conducted solely in an acute care setting were also excluded
from the final review. Studies designed to specifically test the efficacy of neuromuscular
electrical stimulation (NMES; i.e., intervention group treatment: NMES + conventional
physical therapy vs. control group treatment: conventional physical therapy) were excluded
from the review.
Assessment of methodological quality

Each reviewer assessed methodological quality of the included study independently using
the PEDro criteria.14 Results were compared and discrepancies were discussed using PEDro
operational definitions to reach agreement. Interpretation of the PEDro score was as follows:
score greater than 9 excellent methodological quality; score between 6 and 8 good
methodological quality; score between 4 and 5 fair methodological quality; and score lower
than 4 poor methodological quality.
Results
Included and excluded studies
Thirty studies were identified as highly relevant for the review. After further screening, 11
studies were excluded because they did not satisfy inclusion criteria (5 evaluated acute-care
Pozzi et al. Page 4
interventions, 3 focused on NMES, one evaluated home-based exercise versus no exercise,

one was not a peer-reviewed publication, and one was not found in full text version). The
characteristics of the included studies and interventions are summarized in Table 1. Studies
were subdivided into separate categories for discussion including: 1) Strengthening

Exercises, 2) Aquatic Therapy, 3) Balance Training, and 4) Clinical Environment.
Methodological quality assessment

Of the 19 studies that were included in this analysis, 3 were ranked as excellent, 12 were
ranked as good, 4 were ranked as fair and 0 were ranked as poor using the PEDro
classification (Table 2). Of the 19 studies, only 7 studies included an a priori power
analysis.
Participant characteristics
All studies included patients who were scheduled for unilateral TKA for primary knee OA
and the average age across studies ranged from 65 to 73 years (Table 3). One study included
subjects who underwent either unicompartmental or total knee arthroplasty.15 Most studies
did not clearly state inclusion and exclusion criteria, which varied across studies. One study
required KL grade greater than 2 for pre-operative enrollment.16 One study required
preoperative knee ROM greater than or equal to 90 degrees.17 Most of the studies excluded
subjects who had comorbidities, had complications after the surgery, and subjects who were
not able to provide consent. Two studies excluded patient with contralateral painful OA.10,18
Two studies excluded subjects with BMI greater than 40.10,19 Three studies excluded
patients who were not able to walk without assistive devices.20-22 Two studies did not report
information regarding inclusion/exclusion criteria.23,24
Strengthening Interventions
Petterson et al. found that the use of a progressive strengthening protocol (with or without
NMES) after TKA produced significantly better 12-months outcomes in terms of quadriceps
strength (+21%), Timed Up and Go (TUG) and Stair Climbing Test (SCT) times (-24% and
-44%, respectively), and distance walked in the Six Minute Walk (6MW) test (+15%)
compared to an embedded cohort in their RCT that received standard rehabilitation
focused on functional trianing.10 Similarly, a 4-week strengthening protocol using a whole
body vibration platform demonstrated significant improvements in quadriceps strength
(84%), TUG time (32%), and flexion range of motion (ROM) (16%).25 However, this
protocol did not produce better outcomes than 4 weeks of a traditional progressive resistive
exercise protocol. An intensive functional rehabilitation protocol produced better outcomes
than a standard rehabilitation protocol 4 months and 6 months after TKA for the 6MW
(8.5% difference), the Western Ontario and McMaster Universities Arthritis Index
(WOMAC) (10.5% difference), WOMAC pain score (a 10.5% difference), and WOMAC
difficulty score (10.5% difference).26 However, these improvements were not maintained at
the 12-months follow-up. Evgeniadis et al.16 reported that individuals discharged from an 8-
weeks home supervised strengthening exercise program had significantly greater knee
flexion and extension ROM compared to a control group who only received inpatient
rehabilitation (flexion, 98.42 and 80.42; extension, -0.8 and -6.42, respectively). In
Pozzi et al. Page 5
contrast with these results, Levine et al.27 in a non-inferiority trial found that outpatient
physical therapy that included ROM and progressive restive exercises did not improve
flexion and extension ROM, WOMAC score, or get-up-and-go tests to a greater extent than
a protocol that included only NMES and home-based exercises.
Aquatic Therapy
Patients enrolled in a water based exercise program on the 6th postoperative day had on
average 5% better WOMAC scores at the 3-,6-,12-,24-month follow-up after TKA
compared to patients that started the same program on the 14th postoperative day.15 These
differences were not significant, but the effect size ranged from 0.22 at the 6-month follow-
up to 0.39 at the 24-month follow-up. Valtonen et al.28 reported significantly better knee
flexion (36%) and extension (30%) power, habitual walking speed (8%), and stair climbing
time (14%) in subjects who underwent a 12-weeks of a water based resistance exercise
program compared to subjects who did not receive any intervention (participants were
instructed in maintain their usual level of activity). However, only knee extensor and flexor
power remained significantly different between groups 12-months after TKA.29 In a study
that compared a 6-week aquatic program to 6 weeks of land-based therapy,30 there were no
between group differences for 6MW, stair climbing power, WOMAC score, or knee flexion
and extension ROM.
Balance Training
Piva et al.20 found that a 6-weeks of balance specific training in addition to an intensive
functional rehabilitation protocol produced increased self-selected gait speed by 8% and
single leg stance time by 24% compared to baseline. The control group demonstrated 1%
reduction in gait speed and 6% decrease in single leg stance time, although significance
between groups was not assessed in this study. Similarly, Liao et al.19 found that subjects
enrolled in an 8-week balance specific rehabilitation protocol had significantly better single
leg stance times (20%) and faster gait speeds in the 10-meters walk test (18%) compared to
subjects enrolled in intensive functional rehabilitation that did not include balance
retraining. Moreover, subjects in the experimental group had also better WOMAC scores
(13%), longer functional reach (31%), and took less time to complete the TUG and the SCT
(both 9% difference). In contrast to these findings, Fung et al.18 reported that the addition of
15 minutes of balance specific exercises executed on a Wii-Fit Balance Board to standard
physical therapy did not produce better outcome in terms of knee flexion and extension
range of motion, two minute walk test, activity specific balance confidence scale, lower
extremity functional scale compared to adding 15 minutes of conventional strength and
balance training.
Clinical Settings
Rajan et al.21 and Mockford et al.23 reported that subjects enrolled in standard outpatient
physical therapy achieved similar ROM 12 months after TKA compared to subjects who
were not enrolled in outpatient physical therapy. Furthermore, Mockford et al.23 did not find
differences between groups for the Oxford Knee Score, Bartlett patellar score and SF-12
score 12 months after TKA. Other authors have found that home-based and clinic-based
rehabilitation protocols generated similar improvements in WOMAC score, knee rating
Pozzi et al. Page 6
scale, 30-second stair test, 6MW, and knee flexion room 12 weeks and 12 months following
TKA.17 No differences were found between ROM, leg extensor power, 30-second sit to
stand repetition, walking velocity, and self-reported measure of function for a group who
attended group-based outpatient rehabilitation and one who followed a home-based

rehabilitation program.31
Similarly, subjects enrolled in a telerehabilitation program that was remotely supervised by a

physical therapist obtained similar improvements in WOMAC,22,24 knee ROM,22,24 Berg
balance scale,24 30-second chair rise test,24 TUG,22,24 and the Tinetti test24 compared to a
group that attended standard rehabilitation. These results were maintained 4 months after
discharge from physical therapy.24 Kaupilla et al.32 reported that subjects enrolled in a 10
day multidisciplinary rehabilitation program after primary TKA did not attain faster
recovery or better outcomes compared to subjects enrolled in standard rehabilitation. These
authors found that both treatments were effective at improving scores on the WOMAC, 15-
meters walk test, SCT, peak knee extension torque and knee ROM compared to pre-
operative values.
Discussion
Strengthening Interventions
Although quadriceps weakness is a hallmark characteristic of OA, there is a precipitous
decline in strength the first few weeks after surgery.33-35 This is a direct consequence of the
surgical procedure, immobilization, atrophy and primarily neuromuscular inhibition.36,37
Quadriceps strength predicts 28, 26, and 37% of the variability in the TUG, SCT and 6MW
tests respectively, indicating that quadriceps strength is the stronger predictor of functional
performance following TKA.10 Therefore, it is imperative to address quadriceps strength
deficits following TKA.
This was highlighted in the report by Petterson et al.10 who compared outcomes of
progressive strengthening protocols (with or without NMES) to an embedded cohort of
individuals (standard of care group) who did not receive progressive strengthening after
TKA. One year after TKA, subjects enrolled in either progressive strengthening group (with
or without NMES) had significantly higher quadriceps strength and better performance-
based test results (TUG, SCT, 6MW) compared to a group that was enrolled in standard
care. ROM in subjects in both progressive strengthening arms was excellent and three
months after TKA, subjects had 115 degrees of knee flexion and nearly full extension. TUG
times were approximately 8 seconds. There was no difference between progressive
strengthening and standard of care groups in self-reported functional ability or knee ROM,
suggesting that self-reported measures capture different domains of disability than do
performance-based tests. This discrepancy has been substantiated by several others who
have found that performance-based tests are driven by muscle strength and self-report
questionnaires are driven by pain.38-42
Johnson et al.25 assessed the effectiveness of using whole body vibration as a means of
administering general lower extremity strengthening exercises. The control group received
progressive strengthening exercises based on the protocol published by Stevens et al.,43
Pozzi et al. Page 7
while the experimental group received progressive strengthening exercises using a whole
body vibration platform. To ensure progression, exercise and vibration amplitude and
duration were systematically increased. Similar improvements of extensor strength, pain
level, and TUG time were found between groups after 4 weeks of treatment and subjects in
the experimental group did not report any adverse effect of vibration exercises. TUG times
were near age-matched values and were similar between groups 7 to 10 weeks after TKA
(7.8 s in the vibration group and 8.8 s in the exercise group). The vibration group had 116
degrees of total range of knee motion, which was 10 degrees more than the exercise group,
but neither group demonstrated significant improvements relative to pre-operative values.
The authors suggest that whole body vibration may provide a valid alternative to traditional
strengthening exercises after TKA, but these findings must be substantiated in larger trials
with longer-term follow-up. The accuracy of equivocal (or non-superior) findings from a
study with such a small sample size (16 subjects), no long-term follow-up, and no a priori
power analyses is questionable until corroborated by additional evidence.
Moffet et al.26 developed a rehabilitation protocol for patients after TKA based on the motor
learning and training-specificity principles called intensive functional rehabilitation (IFR).
The protocol involved 12 therapist-supervised sessions (duration of 60-90 minutes) with
individualized home exercises executed on the days without supervised treatment. The IFR
included a warm-up, specific strengthening exercises, functional task-oriented exercises,
endurance exercises, and cool-down period. Seventy-seven subjects were randomized to
either receive IFR or usual care. The authors did not control what usual care the control
group received, but did collect that information. The authors only reported that 10 subjects
in the control group received home rehabilitation services after TKA, but did not describe
the exercises or progression that occurred in that group. Four to 6 months after TKA,
subjects randomized to receive IFR had greater improvements in the total WOMAC score
and the WOMAC pain score, as well as walked a further distance during the 6MW
compared to the control group. One year after surgery, there were no significant differences
between the groups and only 43.5% of subjects (30 of 69) had 6MW distances that were
within normal ranges. Of those 30 subjects with normal 6MW values, 20 were in the IFR
group.
Evgeniadis et al.16 randomized 72 patients in three groups of 24 subjects each. All subjects
were enrolled in standard inpatient rehabilitation that lasted 12-14 days, but one group
underwent a home-based exercise program for three weeks prior to surgery that focused on
strengthening the trunk and upper body. The control group received no additional therapy,
while the third group underwent eight weeks of home-supervised exercises to strengthen the
lower extremity. Active ROM of the knee and functional ability (measured using the Iowa
Level of Assistance Scale) were collected during the 10th and 14th weeks after the surgery.
Ten weeks after surgery, patients enrolled in the postoperative exercise program presented
with greater range of motion (both flexion and extension) and better functional ability
compared to the preoperative exercise and control groups. Fourteen weeks after surgery, the
postoperative exercise group had significantly greater knee ROM compared to the other two
groups. At this time point, knee ROM values were: 80.42 and -6.42 for the control group;
80.73 and -5.7 for the preoperative exercise group; 98.42 and -0.8 for the postoperative
Pozzi et al. Page 8
exercise group. The authors concluded that only a postoperative exercise program is
effective at restoring knee ROM after surgery, although no group in this study averaged
more than 100 degrees of knee flexion 14 weeks after TKA.
In a non-inferiority randomized trial of 70 subjects, Levine et al.27 evaluated the effect of

NMES on range of motion, WOMAC scores and Get Up and Go times. Subjects were
randomized to receive supervised physical therapy that included range of motion (ROM)
and strengthening exercises or home-based treatment that included NMES and ROM
exercises. NMES treatment started 14 days preoperatively and lasted until 60 days
postoperatively with no NMES the day before or after surgery. These authors found no
differences between groups for ROM, self-reported functional ability (WOMAC) and TUG
times and concluded that home exercises with NMES may provide an option for
simplifying and reducing cost of the postoperative TKA recovery process without
compromising quadriceps strength or patient satisfaction. However, the authors did not
provide a detailed description of either rehabilitation protocol and there was no information
on dose, duration, or frequency of treatments. No cost analysis was performed. Six months
following surgery, the Get Up and Go times of both the experimental and control groups
were 10.64 and 10.25s, respectively. These values were greater (took longer to complete the
task) than other published reports examining NMES. At the same time point, the
experimental and control groups of the study by Stevens-Lapsley et al.11 completed the task
in 7.1 and 8.8 s, respectively. Experimental and control groups of the study of Petterson et
al.10 reached better values 3 months following TKA (8.29 and 8.02 s). These slower times
from the subjects by Levine et al.27 suggest that subjects in this study were under-
rehabilitated. Quadriceps strength, the impairment targeted by NMES, was not evaluated.
Post-operative, progressive exercise programs improve outcomes to a greater extent than

postoperative care that does not include elements of muscle strengthening. The results from
both randomized arms of the study by Petterson et al.10 produced excellent range of motion
and TUG times within 3 months of TKA. Subjects in the study by Moffet et al.26 had better
WOMAC scores and 6MW distances, with the majority of subjects in the exercise group
achieving normal 6MW distances one year after TKA. Although subjects in exercise group
in the study by Evgeniadis et al.16 had better outcomes then a control group, mean knee
flexion in the postoperative exercise group was still less than 100 degrees. The range of
motion results in the other two groups that did not receive post-operative strengthening
exercise were extremely low with knee flexion range of motion of ~80 degrees and
substantial knee flexion contractures (lacking ~6 degrees of extension). Although the post-
operative group was supervised, it was performed at home. It is possible that the poor
outcomes in the exercise group are a consequence of the environment in which the
rehabilitation was performed. Without use of resistive equipment and modalities that are
commonplace in a physical therapy facility, at-home exercise programs may not provide
optimal outcomes. The studies by Petterson et al.10 and Moffett et al.26 were performed in a
rehabilitation clinic and this may be related to the substantially better outcomes found in
these two studies compared with the outcomes reported by Evgeniadis et al.16 Collectively,
the findings from these studies on exercise suggest that not only should post-operative
strengthening exercises be a primary component of post-operative care, but the exercise
Pozzi et al. Page 9
programs should be supervised and progressed as the patients meet clinical and strength
milestones.
Aquatic Therapy
Proponents of water-based rehabilitation protocols argue that exercising in warm water may
reduce the stress on the joint and allow the individual to strengthen their lower extremity
using water as resistance while taking advantage of the weight reducing effects of buoyancy.
However, water-based rehabilitation may increase the per-session cost and there have been
few cost-effectiveness or comparative effectiveness studies assessing aquatic therapy in a
post-surgical TKA population.
Using principles of buoyancy may be most effective in the early stages after TKA when pain
or muscle impairments limit the ability to perform resistance exercises in weight bearing
positions. Liebs et al.15 found that water-based therapy can be safely started as early 6 days
after TKA as long as the wound is covered with a waterproof adhesive dressing. These
authors also revealed that subjects randomized to start water-based therapy on the 6th
postoperative day had better WOMAC, SF-36, and Lequense Knee scores 12 and 24 months
after TKA compared to subjects who were randomized to start aquatic therapy on the 14th
postoperative day. While these results were not statistically different between group, the
effect size of the intervention on WOMAC score (range 0.22 at 6 months to 0.39 at 24
months) was similar to the effect of nonsteroidal anti-inflammatory drugs on functional
limitations associated with knee OA. The change in WOMAC score also exceeded the
minimal clinical important difference cut-off 24 months following surgery. However, these
authors used only self-reported measure of function and did not compare the outcomes of
aquatic based therapy to other land-based rehabilitation paradigms.
Valtonen et al.28 analyzed the effect of a water-based resistance training program on

mobility limitations (walking speed and stair ascent time), self-reported function
(WOMAC), and lower-extremity strength (isokinetic power and quadriceps cross sectional
area). Fifty subjects were randomized to either an aquatic program in which progressive
strengthening exercises were performed in the pool or were advised to maintain their usual
physical activity level. Intensity of the treatment was also estimated in 6 subjects (3 male
and 3 female) using the Rate of Perceived Exertion scale (0 = no effort; 20 = maximal
effort) and a heart rate monitor. Over the 12 weeks of training, the average RPE value was
17 and the average heart rate was 116 (73% of the heart rate maximal for those subjects),
which suggest that training intensity was high. At the end 12 weeks of training, subjects in
the experimental group had better knee flexion and extension power, greater cross sectional
area, faster self-selected walking speed, and faster stair ascent time compared to control
subjects. No differences were found for WOMAC score. Twelve months after the surgery,
the knee extensor and flexor powers were still 32 and 48% higher, respectively, in the
experimental group compared to control group. No differences between groups were
detected in relation to cross sectional area, walking speed, and stair ascent time at the one
year follow-up.29 These findings lend evidence to the benefit of high-intensity and
progressive exercises performed on land or in water, although the subject sample was
comprised of subjects in the late stages of recovery after TKA (average 10 months post-
Pozzi et al. Page 10
operative). This exercise program may expedite recovery and be more advantageous to
subjects early after TKA, although future work should be conducted to explore this
possibility.
In contrast, Harmer et al.30 randomized 102 patients scheduled for TKA to receive either
land-based or water-based physical therapy. Both groups attended therapy twice a week for
6 weeks and each session lasted for 60 minutes. The same therapist supervised both water-
and land-based treatment and the exercise prescription was highly standardized to ensure
that the only difference between treatment groups was the medium (water versus land).
Subjects were evaluated 8 and 26 weeks after TKA and there were no differences between
groups for WOMAC score, knee range of motion, 6MW, and stair climbing power, although
both groups demonstrated significant improvement compared to baseline. The authors
concluded that water-based therapy was not particularly advantageous with respect to
functional outcome or clinical metrics, although it may be a valid alternative treatment for
rehabilitation after TKA.
Balance training
Balance is a critical impairment in patients with TKA and persistent muscle weakness.
Patients after TKA are at a higher risk for falling and further orthopaedic injury.44,45
Resolving balance impairments after TKA should be an important goal of physical therapy.
Two studies with similar methodology assessed the effectiveness of adding specific balance
exercises (agility and perturbation drills) to an IFR protocol. Piva et al.20 found that subjects
who were randomized to receive 6 weeks of balance training had faster self-selected walking
speed and performed better on a single leg stance test for unilateral balance than subject
randomized to receive only the IFR protocol. Both groups in this study demonstrated similar
improvements in the WOMAC and 30 sec chair rise test. However, only confidence
intervals were reported and tests of significance were not performed in this study. Liao at
al.19 found that the addition of balance exercises to a post-operative rehabilitation program
significantly improved functional forward reach, single leg stance, sit-to-stand test, stair
climbing time, 10m walk time, TUG scores, and the WOMAC to a greater extent than a
control group that did not receive balance retraining exercises. It should be noted that Liao
et al.19 had a larger sample size (130 versus 43) and longer intervention (8 versus 6 weeks)
than the study by Piva et al.20 Additionally, subjects randomized to receive balance
retraining in the study by Liao et al. also had a longer duration session than subjects in the
control group in the same study (up to 90 minutes versus 60 minutes). Considering a twice
per week physical therapy plan of care, the 30 additional minutes of therapy at each session
increased total treatment time by up to 5 hours.
New interactive technologies have been recently applied to rehabilitation sessions with the
aim to increase strength and balance while improving patient stimulation, compliance and
satisfaction with treatment. Fung et al.18 tested the use of integrating the Wii-Fit game into
a rehabilitation paradigm after TKA. In addition to standard therapy, subjects randomized to
the experimental group received 15 minutes of Wii-Fit gaming activity, while the control
group received 15 minutes of additional lower extremity exercise. There were no differences
between groups for range of motion, two-minute walk test, numeric pain rating scale,
activity-specific balance confidence scale, the lower extremity functional scale, and length
of outpatient rehabilitation. These findings suggest that the addition of Wii-Fit as an
alternative to some lower extremity strengthening may be an appropriate rehabilitation tool.
Clinic Environment
Outpatient physical therapy conducted in a clinic-based setting is advantageous in that a
physical therapist can directly monitor patient progress and modify the intervention with
changes in the patients functional status. However, physical therapy conducted in an
outpatient clinic is more expensive than home exercises and requires that the patient travel
to the clinic, which may be difficult for an elderly population. Therefore it is important to
determine if supervised outpatient rehabilitation is superior to no standardized care, home-
based rehabilitation (with phone call monitoring) and/or telerehabilitation (where the patient
is supervised remotely by a therapist).
Rajan et al.21 randomized 116 to receive either inpatient therapy or inpatient plus outpatient
therapy. However, the dose, frequency and intensity of outpatient therapy were not
quantified in this study and subjects were excluded if they used an assistive device to walk.
The authors only state that outpatient physiotherapy is usually given, on average, 46 times
after discharge from hospital, which is considerably less than the outpatient sessions
reported in other randomized trials.10,12,19,20 Although outpatient physical therapy typically
provides strengthening, stretching and functional retraining exercises, only knee ROM was
assessed in this study. In the group that received outpatient therapy, the knee range of
motion was 92 at baseline and increased to 95, 97 and 98 during the 3, 6, 12 months
follow-up. Similarly, in the group that did not receive outpatient therapy, the range of
motion was 90 at baseline and increased to 92, 93 and 96 during the follow-up
evaluations. Based on these numbers, no differences of knee ROM were found between
groups 3, 6, and 12 months after TKA, although neither group had achieved mean flexion
ROM that exceed 100.
Similarly, Mockford et al.23 randomized 143 patients in two groups: one received outpatient
therapy, the other only inpatient therapy. Minimal information regarding the inpatient
treatment was provided and it was reported to start on postoperative day 1 and include
functional and strengthening exercises. No detailed information was given regarding the
dose, frequency or intensity of the outpatient therapy and this treatment arm was only
described as standard outpatient physiotherapy regime. No differences between groups

were found for flexion and extension ROM, Oxford Knee Score, Bartlett Patellar Score, and
SF-12 twelve months after surgery. These authors concluded: a standard routine course of
outpatient physiotherapy does not offer any benefit in the long-term to patients undergoing
TKA. However, these authors did not provide information about the inclusion and
exclusion criteria that defined their sample.
The conclusions by Rajan et al.21 that there is no need for outpatient physiotherapy after
total knee arthroplasty and by Mockford et al.23 that a standard routine course of
outpatient physiotherapy does not offer any benefit in the long-term to patient undergoing
TKA are not supported by the methodologies and results from these studies. In both
studies, there was no standardization or description of the protocol or duration of the
outpatient physical therapy intervention and only range of motion and self-reported
outcomes were assessed to make determinations about the effectiveness of outpatient
rehabilitation. Additionally, one year after surgery, subjects in both studies had knee flexion
range of motion (97 and 108 degrees) that was lower than the cutoff for functional range of
motion (110 degrees)46 and less than the 120 degrees reported by Petterson et al.10 These
low knee flexion angles from Rajan et al.21 and Mockford et al.23 suggest that neither
treatment arm was effective at managing post-operative range of motion impairments.
To determine the effectiveness of home-based therapy monitored via telephone contact,

Kramer et al.17 randomized 160 patients to receive either clinic-based or home-based
therapy. Both groups were given two booklets of ROM and strengthening exercises with the
prescription to perform them at home three times per week for 12 weeks. A physical
therapist familiar with the protocol followed up weekly with the home-based group to
monitor adherence and compliance with the protocol. The clinic-based group attended
therapy twice a week for 12 weeks for one-hour sessions. At the 12th and 52nd week follow
up, values for WOMAC, SF-36, 6MW, 30-second chair test, knee flexion ROM were
significantly better compared to baseline in both groups and there was no relative advantage
of one group over the other. Both groups had knee flexion less than 100 degrees at the one
year follow-up and 6MW distances were 400 m or less.
Madsen et al.31 also compared home-based and clinic-based rehabilitation. In this study, 80
patients were randomized to receive either home- or clinic-based rehabilitation. The clinic-
based group received 12 group treatment sessions over 6 weeks consisting of: 1)
strengthening and endurance training; 2) educational session on TKA relevant topics; and 3)
discussion sessions where patients were encouraged to share experiences and discuss the
topic of the educational session. The home-based group underwent an initial visit with a
physical therapist in which the home-based training was adjusted to each individual needs.
Additionally, one to two visits with a physical therapist were then planned during the home-
based treatment to further adjust the program. Three and 6 months after TKA, there were no
differences between groups after adjusting for baseline values for the self-reported measures
(Oxford Knee Score, the physical function part of the SF-36, the EuroQol-5 Dimension),
impairment-metrics (leg extension power, pain level during the power test), and
performance-metrics (tandem test for balance, 10m walking test, 30s sit-to-stand and five-
times sit-to-stand tests). The outcome data from this study were presented as percentage
change from baseline, making comparisons to previous work difficult and limiting our
interpretation of the effectiveness of either treatment.
Two different studies compared the use of telerehabilitation to conventional outpatient

physical therapy.22,24 A total of 113 patients were randomized to either receive outpatient
physical therapy or telerehabilitation, which consisted of a teleconference system to allow
therapist to directly and remotely supervise patients during exercises. Tousignat et al.24
required a family member or a friend of the patient to undergo a training session and be
present during therapy to ensure patient safety. Russell et al.22 developed a measurement
tool, which allowed measurement of performance over the internet and allowed the therapist
to obtain high-quality videos of the patient performing the rehabilitation exercises. In both
studies the treatment duration and length was balanced between groups. No differences
between groups were found for the WOMAC, TUG, and flexion and extension ROM at the
end of the treatment and the authors suggest that both outpatient and telerehabilitation are
effective treatment after TKA. Despite the lack of between group differences, both groups
were under-rehabilitated in the study by Russell et al.22 On average, subjects in this group
had residual knee flexion contractures and were unable to do a straight leg raise without a
quadriceps lag, indicating significant residual weakness. Additionally, TUG times in this
group were still greater than 12 seconds at the conclusion of the study, nearly 50% longer
than the TUG times reported by Petterson et al.10 3 months after TKA and the times in the
experimental group reported by Stevens-Lapsley et al.12 only 6.5 weeks after TKA.
The results from the home-therapy and telerehabilitation studies suggest that ROM, strength
and functional impairments are not completely resolved with this type of post-operative
treatment strategy. Although, home-based or telerehabilitation may be beneficial for subjects
who cannot attend clinic sessions or live in remote areas, further studies are need to
ascertain whether home-therapy or telerehabilitation can produce similar outcome compared
with clinic-based progressive strengthening protocol or intensive functional training, which
requires constant and progressive modification of the treatment based on patients specific
progression and needs.
Kauppila et al.32 tested whether a 10-days multidisciplinary rehabilitation program was

effective in achieving faster and greater functional recovery after TKA. Subjects in the
experimental group attended the multidisciplinary program 2 to 4 months after the surgery.
This program involved completing group exercises sessions with a physical therapist and
attending lectures from a variety of health care personnel (orthopaedic surgeon,
psychologist, and nutritionist). The control group followed usual care. The results of this
study showed that this intervention did not improve outcomes or achieved faster recovery
after TKA. However, subjects who undergo TKA often have comorbidities including
depression, obesity, and cardiovascular impairments, and may benefit from a
multidisciplinary rehabilitation treatment after the surgery. Future studies are needed to test
this hypothesis.
Recommendations for Treatment and Future Studies

Based on the results from this review, the optimal outpatient physical therapy protocol
should include: strengthening and intensive functional exercises given through land-based or
aquatic programs, that are progressed as the subject meets clinical and strength milestones.
Due to the highly individualized characteristics of these types of exercises, outpatient
physical therapy performed in a clinic under the supervision of a trained physical therapist
may provide the best long-term outcomes after the surgery. If treatment within an outpatient
clinic is not feasible, supervised or remotely supervised therapy may be effective at reducing
some of the impairments after TKA, although the initial evidence suggests that
telerehabilitation does not resolve range of motion, strength and functional impairments to
the same extent as supervised physical therapy sessions that include progressive exercise.
Although outside the aim of this review, it is important to highlight that early use (starting
from postoperative day 2) of NMES has been suggested to be a necessary treatment to
attenuate the early loss of quadriceps strength after TKA and optimal protocols may include
components not assessed in this review. 12,35-37,47,48
The trials that suggested that outpatient physical therapy is not necessary after TKA lack
methodological control and subjects in all groups appeared under-rehabilitated.21,23,27
Moreover, none of these trials provided evidence that home-based17 or lack of
outpatient21,23,27 care was superior and no metrics were collected with respect to patient
safety, cost or long-term outcomes, which must be evaluated before any conclusions as to
the necessity of outpatient physical therapy can be made. Therefore, we cannot recommend
that post-operative rehabilitation exclude outpatient physical therapy or supervised exercise
programs
Although the mean methodological quality was good (6.9), the PEDro ranking does not
consider three additional attributes that are essential to determining the quality of the study
and evaluating the generalizability and usefulness of the results. First, in any randomized
controlled or comparative effectiveness study, an a priori sample size is required. This
sample size should be based on preliminary data or established clinically important
differences for the metric that will be used as the primary outcome. Only 7 of the studies in
this review included a sample size justification.
Second, exercise and post-operative physical therapy are not a standard treatment. Authors
cannot simply compare one treatment versus standard physical therapy without providing
information about the treatment paradigm, dose, frequency, intensity, criteria for
progression, and evidence of progression and compliance within that group. Future studies
that wish to evaluate a novel or different outpatient treatment to standard physical therapy
should use the best, most effective protocol as the comparison group. These protocols should
include at least 12 supervised and progressive strengthening exercises sessions, which
should start within the first post-operative month, although starting rehabilitation programs
earlier after TKA may produce better outcomes.11,12 Only when comparisons are made to an
optimal treatment we can determine if a different post-operative rehabilitation or exercise
strategy is more beneficial. The majority of studies in this review did not include all
attributes of the comparative or control groups and both arms (experimental and control)
appeared under-rehabilitated with substantial weakness, limited range of motion and
functional deficits. Comparison to normative values should be done in all trials to compare
not only the effectiveness between treatments, but also the effectiveness of the treatment to
restore normal age-matched functional ability.
Finally, the outcome metrics must align with the goals of the intervention and should be
related to functional performance. Several authors have concluded that self-reported
measures of function are driven mostly by pain, and should not be used in isolation to
measure post-operative outcomes.38-42 Performance-based metrics are required to obtain a
complete description of the recovery after TKA. Lower extremity strength, particularly
quadriceps strength, is highly related to functional performance and should certainly be
included in any intervention that targets muscular impairments after TKA. Although knee
range of motion is a concern of most patients and clinicians, this value has little relation to
functional performance once at least 110 degrees of flexion are achieved.46 For studies of
OA and TKA, the Osteoarthritis Research Society International recommends that the 30
second chair rise test, 410m fast-paced walk test, a timed stair climbing test, TUG and
6MW be included as outcome measures.49
Most studies in this review also had strict inclusion and exclusion criteria for patient
selection and excluded many subjects with co-morbidities. The results from these studies
may not be applicable to all patients who undergo TKA, given that many patients with end-
stage OA have co-morbid orthopaedic and cardiovascular conditions. Future studies should
evaluate a broader TKA cohort.
In conclusion, progressive exercise is critical to recovery after TKA. There is a large

decrease in quadriceps strength immediately after TKA, which is attributed to activation
deficits and atrophy.33,37 This loss of strength is related to functional impairments10,35 and
biomechanical asymmetries.50 Progressive exercise protocols and early application of
NMES should be used to attenuate early quadriceps weakness and the associated
impairments. Further work is needed to fully elucidate the relationship between post-
operative exercise protocols and outcomes, given that most studies did not accurately
describe the usual care groups that were included as treatment arms in these randomized
trials.
Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
Acknowledgments
Funding: Funding for this work was provided by National Institutes of Health K12 HD055931
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NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Table 1
Studies and intervention Characeristics
Groups Program Type Supervised session Start of program End of program Session Frequency Intensity Primasy measures Secondary measures Last follow-up
Pozzi et al.
individual or group duration
Evgeniadis Intervention Strengthening lower extremities Home supervised After discharge 8 weeks
et al. 2008 Unknown Unknown Unknown ILAS AROM 14 weeks
Control No outpatiet therapy Unknown Unknown
Fung et al. Intervention Strengthening exercise + 15 Average 37 day after Average 54 days
2012 min of Wii-Fit game surgery ROM; 2-minutes walk
Control Strengthening exercise + 15 Individual Average 46 day after Average 53 days 60 minutes Unknown Exercised progressed test; NPRS; LEFS; Unknown
min additional lower leg surgery ABCS; LOR.
strengthening
Harmer et Intervention Water-basedtherapy Individual

al. 2009 SCP; WOMAC; VAS
2 weeks postoperative 6 weeks 60 minutes 2/week Exercised progressed 6MW 26 weeks
pain; ROM
Control Land-based therapy Individual
Johnson et Intervention Strengthening exercises on Individual

al. 2010 whole body platform KISTR; CAR; TUG;
One month 4 weeks 60 minutes 3/week Exercised progressed 4 weeks
VAS-pain; ROM
Control Strengthening exercises Individual
Kauppila Intervention Multidisciplinary rehabilitation Group (n=?) 2/4 months postoperative 10 days From 30 daily Unknown
et al. 2010 to 45 15MT; SCT; AROM;
minutes WOMAC 12 months
KISTR
Control Usual care Unknown Unknown Unknown Unknown Unknown Unknown
Kramer et Intervention A Clinic-based outpatient Individual 1 hour 2/week Exercised progressed KSRS; WOMAC;
al. 2003 Week 2 postoperative Week 12 postoperative MOSSF; 6MW; 12 months
Intervention B Home-based Phone calls Unknown 3/day Unknown 30SST; AROM
Levine et Intervention NEMS + ROM exercise Home-unsupervised 14 days preoperative 60 days postoperative
al. 2013 Unknown Unknown Unknown KSRS; WOMAC; TUG 6 months
Control ROM + strengthening exercises Clinic-based supervised Unknown Unknown
Liao et al. Intervention Functional training + balance 60 to 90 FRT; SLST; 10MW;

2013 Clinic-based supervised Unknown 8 weeks minutes Unknown Exercised progressed TUG; 30SCR; 8 weeks
Control Functional training 60 minutes WOMAC
Liebs et al. Intervention A Satandard + aquatic therapy 6th postoperative day

2012 Clinic-based supervised up to 5 weeks 30 minutes 3/week Unknown WOMAC SF-36; LKS 24 months
Page 19
Intervention B Standard + aquatic therapy 14th postoperative day

Pozzi et al.
Madsen et Intervention Strengthening andendurance Clinic-based group 4 to 8 weeks 6 weeks 2/week

al. 2013 exercises + educational supervised (n=4 to 8) postoperative
sessions AROM; LEP; TT; 10MW;
Unknown Exercised progressed OKS; SF-36; EQ-5D 6 months
30SCR; 5TSS; VAS-pain
Control Endurance, strengthening and Home-based 4 weeks postoperative Unknown Unknown
fnctional exercises
Mockford Intervention Standard therapy Clinic-based supervised

et al. 2008 ROM; OKS; BPS;
Unknown Unknown Unknown Unknown Unknown 12 months
SF-12
Control No outpatiet therapy Home-unsupervised
Moffet et Intervention Intensive functional training Clinic-based supervised 2 months potoperative 6 to 8 weeks 60 to 90 2/week Exercised progressed
al. 2004 minutes 6MW WOMAC; SF-36 12 months
Control Usual care Unknown Unknown Unknown Unknown Unknown Unknown
Petterson Intervention A Progressive strengthening Clinic-based supervised 3/4 weeks postoperative 6 weeks 2or3/weeks Exercised progressed
et al. 2009 KISTR; CAR; TUG;
Unknown SF-36; KOS-ADL; AROM 12 months
SCT; 6MW
Control Usual care Unknown Unknown Unknown Unknown Unknown
Piva et al. Intervention Functional training + balance

2010 Clinic-based supervised 2/4 months postoperative 6 weeks Unknown 2/week Exercised progressed WOMAC; LEFS WS; SLTS; 5TSS 6 months*
Control Functional training
Rajan et Intervention Outpatient therapy Clinic-based supervised

al. 2004 Unknown Unknown Unknown Unknown Unknown ROM 12 months
Control No outpatiet therapy Unknown
Russel et Intervention Home-remotely supervised PSFS; SQLU; TUG; VAS-

al. 2011 Outpatient therapy 1 week postoperative 6 weeks 45 minutes 1/week Unknown WOMAC 6 weeks
Control Clinic-based supervised pain
Tousignant Intervention Functional training Home-remotely supervised 8 weeks 60 minutes 2/week
et al. 2011 WOMAC; TUG; TinT;
Unknown Unknown ROM; BBT; 30SCR 4 months
SMAF
Control Functional training Home/Clinic supervised 8 weeks 60 minutes Unknown
Valtonen Intervention Outpatient aquatic therapy Group-based supervised 12 weeks 60 minutes 2/week Exercised progressed
et al. 2010 (n=4 to 5) Average 10 months WS; SCT; WOMAC;
postoperative MP; MCSA 12 weeks*
Control No intervention Unknown Unknown Unknown Unknown Unknown
Valtonen Intervention Outpatient aquatic therapy Group-based supervised Average 10 months 12 weeks 60 minutes 2/week Exercised progressed WS; SCT; WOMAC;
et al. 2011 (n=4 to 5) postoperative MP; MCSA 12 months*
Page 20
Control No intervention Unknown Unknown Unknown Unknown Unknown

Pozzi et al.
*
Time from randomization
Abbreviation: PCI, physiological cost index; HHS, Hospital of Special Surgery Scale; KRSR, Knee Society Rating Scale; AKS, American Knee Society clinical score; OKS, Oxford Knee Score; SF-36, short form 36; ILAS, Iowa lower extremity scale; AROM, active range of
motion; ROM, range of motion; 2MW, two minute walk test; NPRS, numeric pain rating scale; LEFS, lower extremity functional scale; ABCS, activity specific balance confidence scale; LOR, length of outpatient physical therapy; 6MW, six-minutes walk test; SCP, stair
climbing power; WOMAC, Western Ontario and McMaster Universities Arthritis Index; VAS, visual analog scale; 15D, Fifteen-dimensional quality of life, 15MT, Fifteen meters test; KISTR, Knee isometric strength; MOSSF, Medical outcome study short form; 30SST, thirty
second stair test; FRT, functional reach test; SLST, single leg stance test; 10MW, Timed ten meters walk; 30SCR, Thirty second chair rise test; LKS, Lequense knee score; EQ-5D, Euro Qol-5Dimension; LEP, leg extensor power; TT, tandem test; 5TSS, Five time sit-to-stand;
BPS, Bartlett patellar score; CAR, central activation ration; PSFS, patient specific functional scale; SQLU, Spitzer quality of life uniscale; GRS, global rating scale; SCT, stair climbing test; TUG, timed up-and-go test; BBT, berg balance test; TinT, Tinetti test; SMAF,
Functional anatomy measurements system; MP, muscle power; MCSA, muscle cross sectional area.
Page 21
Table 2
Methodolical quality assessment.
PEDro Criteria
Pozzi et al.
1 2 3 4 5 6 7 8 9 10 11 TOTAL
Evgeniadis et al. 2008 1 1 0 1 0 0 0 0 1 1 1 6

Fung et al. 2012 1 1 0 1 0 0 1 1 1 1 0 7
Harmer et al. 2009 1 1 0 1 0 0 0 1 1 1 1 7
Johnson et al. 2010 1 1 0 1 0 0 0 0 1 1 1 6
Kauppila et al. 2010 1 1 1 1 0 0 0 1 1 1 1 8
Kramer et al. 2003 1 1 0 1 0 0 1 0 1 1 1 7
Levine et al. 2013 1 1 0 1 0 0 0 0 1 1 1 6
Liao et al. 2013 1 1 0 1 0 0 1 1 1 1 1 8
Liebs et al. 2012 1 1 1 1 0 0 0 0 1 1 1 7
Madsen et al. 2013 1 1 1 0 0 0 0 0 1 0 0 4
Mockford et al. 2008 0 1 0 1 0 0 0 1 1 1 0 5
Moffet et al. 2004 1 1 0 1 0 0 1 1 1 1 1 8
Petterson et al. 2009 1 1 0 1 0 0 0 0 1 1 1 6
Piva et al. 2010 1 1 1 1 1 0 1 0 1 1 1 9
Rajan et al. 2004 1 1 0 1 0 0 1 1 1 1 1 8
Russel et al. 2011 1 1 1 1 0 0 1 1 1 1 1 9
Tousignant et al. 2011 0 1 0 0 0 0 0 1 1 1 1 5
Valtonen et al. 2010 1 1 1 1 0 0 1 1 1 1 1 9
Valtonen et al. 2011 1 1 1 1 0 0 1 0 1 1 1 8
NOTE: PEDro criteria: 1. Eligibility criteria were specified. 2. Random allocation. 3. Concealed allocation. 4. Baseline similarity between groups. 5. Subject blinding. 6. Therapist blinding. 7. Assessor
blinding. 8. Follow-up >85%. 9. Intention-to-treat analysis. 10. Between-group statistical comparisons. 11. Point measures and measures of variability reported. Item scoring: 1 = present, 0 = absent.
Page 22
Table 3
Participant characteristics
Groups Number of subjects Total number of subjects lost Age Sex (% of female)
Pozzi et al.
Evgeniadis et al. 2008 Intervention 24 9 68.6 70%
Control 24 4 69.4 87%

Fung et al. 2012 Intervention 27 0 68 58%
Control 23 0 68 42%
Harmer et al. 2009 Intervention 53 4 67.8 57%
Control 49 2 68.7 57%
Johnson et al. 2010 Intervention 11 3 67 25%
Control 10 2 68.5 50%
Kauppila et al. 2010 Intervention 44 8 70.7 76%
Control 42 3 70.6 79%
Kramer et al. 2003 Intervention A 80 15 68.2 59%
Intervention B 80 22 68.6 55%
Levine et al. 2013 Intervention 35 7 65.1 76%
Control 35 10 68.1 62%
Liao et al. 2013 Intervention 65 7 71.4 79%
Control 65 10 72.9 67%
Liebs et al. 2012 Intervention A 87 21 68.5 70%
Intervention B 98 29 70.9 73%
Madsen et al. 2013 Intervention 40 4 69.9 47%
Control 40 8 66.2 50%
Mockford et al. 2008 Intervention 75 4 69.4 65%
Control 75 3 70.9 58%
Moffet et al. 2004 Intervention 38 0 66.7 56%
Control 39 8 68.7 63%
Petterson et al. 2009 Intervention 41 0 65.4 58%
Control 41 0 65.9 66%

Piva et al. 2010 Intervention 21 3 70 72%
Control 22 5 67 72%
Page 23
Groups Number of subjects Total number of subjects lost Age Sex (% of female)
Rajan et al. 2004 Intervention 56 0 69 64%

Control 60 0 68 61%
Pozzi et al.
Russel et al. 2011 Intervention 31 1 66.2 Unknown

Control 34 1 69.6 Unknown
Tousignant et al. 2011 Intervention 24 3 66 Unknown
Control 24 4 66 Unknown
Valtonen et al. 2010 Intervention 26 1 66.2 Unknown
Valtonen et al. 2011 Intervention 26 1 65.8 Unknown

Study included a second experimental group that is not included in the current review.

Study included a between intervention comparison that is not included in the current review.
Page 24

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Eur J Phys Rehabil Med. 2013 December ; 49(6): 877892.

PHYSICAL EXERCISE AFTER KNEE ARTHROPLASTY: A

functional ability, range of motion and/or performance-based test as outcome measures; 3)

Assessment of methodological quality

interventions, 3 focused on NMES, one evaluated home-based exercise versus no exercise,

were subdivided into separate categories for discussion including: 1) Strengthening

Methodological quality assessment

a protocol that included only NMES and home-based exercises.

and extension ROM.

attended group-based outpatient rehabilitation and one who followed a home-based

Similarly, subjects enrolled in a telerehabilitation program that was remotely supervised by a

In a non-inferiority randomized trial of 70 subjects, Levine et al.27 evaluated the effect of

Post-operative, progressive exercise programs improve outcomes to a greater extent than

Valtonen et al.28 analyzed the effect of a water-based resistance training program on

described as standard outpatient physiotherapy regime. No differences between groups

To determine the effectiveness of home-based therapy monitored via telephone contact,

year follow-up and 6MW distances were 400 m or less.

Two different studies compared the use of telerehabilitation to conventional outpatient

Kauppila et al.32 tested whether a 10-days multidisciplinary rehabilitation program was

Recommendations for Treatment and Future Studies

this review included a sample size justification.

In conclusion, progressive exercise is critical to recovery after TKA. There is a large

4. Health at a Glance: Europe 2010. OECD Publishing; 2010.

93(2):11320. [PubMed: 21248209]

Management and Rehabilitation. American Physical Therapy Association; 2010. p. 1-62.

Studies and intervention Characeristics

individual or group duration

Harmer et Intervention Water-basedtherapy Individual

Johnson et Intervention Strengthening exercises on Individual

Liao et al. Intervention Functional training + balance 60 to 90 FRT; SLST; 10MW;

Liebs et al. Intervention A Satandard + aquatic therapy 6th postoperative day

Intervention B Standard + aquatic therapy 14th postoperative day

Madsen et Intervention Strengthening andendurance Clinic-based group 4 to 8 weeks 6 weeks 2/week

Mockford Intervention Standard therapy Clinic-based supervised

Piva et al. Intervention Functional training + balance

Rajan et Intervention Outpatient therapy Clinic-based supervised

Russel et Intervention Home-remotely supervised PSFS; SQLU; TUG; VAS-

Control No intervention Unknown Unknown Unknown Unknown Unknown

Methodolical quality assessment.

Evgeniadis et al. 2008 1 1 0 1 0 0 0 0 1 1 1 6

Evgeniadis et al. 2008 Intervention 24 9 68.6 70%

Control 24 4 69.4 87%

Control 41 0 65.9 66%

Rajan et al. 2004 Intervention 56 0 69 64%

Russel et al. 2011 Intervention 31 1 66.2 Unknown

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