Special Focus Section 201

Rehabilitative Guidelines after Total Knee

Arthroplasty: A Review
Jaydev B. Mistry, MD1 Randa D. K. Elmallah, MD1 Anil Bhave, PT1 Morad Chughtai, MD1
Jeffrey Jai Cherian, DO2 Tanner McGinn, BS1 Steven F. Harwin, MD3 Michael A. Mont, MD1

1 Center for Joint Preservation and Replacement, Rubin Institute for Address for correspondence Michael A. Mont, MD, Center for Joint
Advanced Orthopaedics, Baltimore, Maryland Preservation and Replacement, Rubin Institute for Advanced
2 Department of Orthopaedics, Philadelphia College of Osteopathic Orthopaedics, 2401 West Belvedere Avenue, Baltimore, MD 21215
Medicine, Philadelphia, Pennsylvania (e-mail: mmont@lifebridgehealth.org; rhondamont@aol.com).
3 Department of Orthopaedic Surgery, Beth Israel Medical Center,
New York, New York

J Knee Surg 2016;29:201–217.

Abstract Rehabilitation following total knee arthroplasty (TKA) continues to pose a challenge for
both patients and providers. In addition, guidelines vary considerably between institu-
tions, which often leave therapy regimens to the discretion of the provider. The lack of

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clear guidelines for rehabilitation may contribute to inadequate recovery of strength
and range-of-motion, resulting in less optimal functional outcomes. Therefore, the aim
of this review was to highlight and discuss a variety of post-TKA rehabilitative modalities
currently available and to provide evidence regarding efficacy and practicality. Specifi-
cally, we assessed the role of and evidence for exercise therapy, aquatic therapy, balance
training, continuous passive motion, cold therapy and compression, neuromuscular
electrical stimulation, transcutaneous electrical nerve stimulation, and instrument-
assisted soft-tissue therapy. Additionally, we proposed general recommendations for
rehabilitation after TKA, and as we specifically described active and obese patients, we
Keywords have included guidelines for these subsets as well. Our review examines the various
► rehabilitation rehabilitative modalities to offer suggestions for recovery of strength and range-of-
► total knee motion after TKA, with a focus on the early incorporation of exercise therapy, balance
arthroplasty training, aquatic therapy, cryopneumatic therapy, neuromuscular electrical stimulation,
► therapy and transcutaneous electrical nerve stimulation. Dedication and commitment to
► outcomes rehabilitation may help patients attain and exceed their preoperative activity levels.

Total knee arthroplasty (TKA) is an excellent option for functional recovery following surgery. For example, it has
patients suffering from end-stage arthritis,1,2 and its success been observed that quadriceps muscle strength may decrease
largely depends on surgical technique and implant longevity, by up to 50 to 60% after the procedure and often fails to return
both of which have improved over the past several decades.3,4 to preoperative levels.8–13 Although orthopedists and thera-
For example, advances in perioperative interventions such as pists employ various techniques to address poor outcomes
the use of computer-assisted navigation and patient-specific following surgery, there is currently no consensus regarding
instrumentation, have demonstrated favorable outcomes and which rehabilitation protocols should be used for improved
are currently undergoing further investigation.5–7 Despite functional outcomes.14,15
these advancements, outcomes following TKA remain depen- Rehabilitation after TKA focuses on recovery of knee
dent on the adequacy of rehabilitation and subsequent range-of-motion (ROM), restoration of knee- and hip-muscle

received Copyright © 2016 by Thieme Medical DOI http://dx.doi.org/

October 13, 2015 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0036-1579670.
accepted after revision New York, NY 10001, USA. ISSN 1538-8506.
January 31, 2016 Tel: +1(212) 584-4662.
published online
March 10, 2016
202 Rehabilitative Guidelines after TKA Mistry et al.

strength, development of functional independence, and the The following rehabilitative modalities were chosen as a
ability to participate in recreational activities.16–18 These are result of the relevance criteria set before the search and
commonly used tangible and patient-reported measures to because they have been frequently utilized in other reviews:
assess postoperative function, and therefore, are often the Exercise therapy, aquatic therapy, balance training, continu-
focus of rehabilitation.16–18 Without rehabilitation, function- ous passive motion, cold therapy and compression, neuro-
al independence and activity levels may not be recovered. muscular electrical stimulation, transcutaneous electrical
Numerous modalities are directed toward regaining strength nerve stimulation, and instrument-assisted soft-tissue thera-
and function, including but not limited to physical therapy, py (see ►Appendix 1 for a summary of the studies).
aquatic therapy, ice/compression, transcutaneous electrical
nerve stimulation (TENS), neuromuscular electrical stimula- Exercise Therapy
tion (NMES), and instrument-assisted soft-tissue therapy. Exercise therapy plays a fundamental role in the postopera-
Different rehabilitation programs, select modalities for their tive rehabilitation of patients after TKA. Different protocols
patients based on practitioner preference, often with little to provide various instructions for the progression of therapy
no explanation of the reason for selection.14,19 after surgery, however, health care professionals often use
With the availability of a large number of postoperative their clinical judgment to make adjustments to optimize
rehabilitative modalities, determining the most suitable regimen results. Common elements in post-TKA exercise therapy
is often difficult. More importantly, there are no consistent or include, but are not limited to: passive knee ROM exercises,
widely implemented guidelines for rehabilitation after TKA,18,20 lower extremity stretches (for the quadriceps, hamstrings,
however, several other reviews21,22 have attempted to address and calf), ice/heat application, gait training, and functional
this topic. While they offer valuable insight into rehabilitation training.23 When exercise protocols are designed, many
following TKA, they did not include several available rehabilita- aspects may vary from therapist to therapist, including

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tive modalities and only provided recommendations for the duration of the regimen and type of exercise included. As
general population. These reviews will be further described in such, there is no “usual care” for patients, which highlights
the discussion. Our report will add to the literature by providing the weakness that many studies do not sufficiently describe
a comprehensive review that includes more rehabilitative “standard rehabilitation.” Bhave and Baker describe a three-
modalities. Additionally, this report will offer recommendations phase physical therapy protocol encompassing the elements
for obese and active patients, as they are growing subsets of the of strengthening, ROM, and functional recovery
population. Therefore, our purpose was to: (1) evaluate the (see ►Appendix 2). This protocol highlights basic strength-
various modalities for post-TKA rehabilitation; (2) specifically ening exercises, ROM stretches, and gait training, among
evaluate differences in rehabilitation for obese and active others. Another set of exercises that are commonly used is
patients; and (3) propose guidelines for rehabilitation after the SAFTE (slide and flex, tighten, and extend) regimen,
TKA for return to activity or sport. however, it is not used by all.24 While seated in a chair, the
patient is instructed to slide the foot back, bending the knee
as much as possible. Keeping the foot stationary, the patient
Methods
then leans back and slides the buttock forward, causing the
A literature search using PubMed, EBSCO Host, and SCOPUS was knee to flex further. Next, the patient is to sit with the knee
performed for this review. We searched studies from the incep- extended and heel on the floor with the ankle in dorsiflexion.
tion of the respective databases up to July 2015. Various The patient should tighten the thigh muscle as if pushing the
combinations of the following search terms were applied: knee downward, holding for 5 seconds before relaxing. While
(knee), (total knee arthroplasty), (knee replacement), (TKA), in the relaxed position, patients are also encouraged to gently
(TENS), (transcutaneous electrical nerve stimulation), (NMES), move the patella from side-to-side.
(neuromuscular electrical stimulation), (rehabilitation), Several studies have evaluated the use of different reha-
(Astym), (exercise therapy), (physical therapy), (aquatic), bilitation programs for post-TKA patients. Petterson et al25
(CPM), (continuous passive motion), (balance), (cryopneumatic), conducted a randomized clinical trial (RCT) with a two-arm
(compression), (ice), (activity), (obesity), and (protocol). progressive strength training program (n ¼ 92, RCT group),
Our search identified 750 abstracts, which were re- one of which utilized NMES, and compared the results with a
viewed by two authors (J. M., M. C.) to determine articles cohort of patients who received the standard rehabilitation
that were appropriate for this report. A consensus for any protocol after TKA. While they were unable to discern signifi-
uncertainties was reached with the help of a third author cant differences for any outcome variable between the two
(R. E.). A total of 211 potentially relevant articles were RCT groups, they found that both arms of the strengthening
identified for further evaluation. Overall, 120 articles were protocol collectively produced significantly better 12-month
determined not to be relevant to rehabilitative modalities outcomes when compared with the standard rehabilitation
and outcomes after TKA or were not in English, and were cohort. The RCT group had significantly greater quadriceps
subsequently excluded. References of the remaining ar- strength (p ¼ 0.007), was 24% faster on the timed-up-and-go
ticles were assessed, and those with potentially relevant test (TUG) (p ¼ 0.004), completed the stair-climb time (SCT)
titles were selected to review their abstracts. This provided test 44% faster (p < 0.001), and walked a 15% greater distance
an additional 28 articles. A total of 119 reports were on the 6-min walk (6MW) (p ¼ 0.003). Additionally, Bade and
included in this review. Stevens-Lapsley23 conducted a prospective cohort study to

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 Rehabilitative Guidelines after TKA Mistry et al. 203

assess the outcomes of a high intensity (HI) rehabilitation extension protocol demonstrated similar rates of improve-
program compared with a lower intensity rehabilitation ment with decreased treatment time, suggesting its utility in
program. They concluded that a HI program leads to better this common obstacle encountered during rehabilitation.
short-term (p < 0.05) and long-term (p < 0.05) functional Invasive modalities, such as botulinum toxin injections and
performance when compared with the control group. The HI soft-tissue releases, are available for the management of knee
group also demonstrated better short-term (p < 0.05) and flexion contractures but are beyond the scope of this review.
long-term (p ¼ 0.08) quadriceps strength. In summary, the primary purpose of exercise therapy is to
Moffet et al26 compared a new intensive functional reha- maximize early ROM, improve strength and pain, and to
bilitation (IFR) program with a control group who received normalize gait mechanics. While there is much debate as to
usual care (which was not defined). Four to six months after the use of an appropriate regimen, there is a consensus that
TKA, the IFR group demonstrated significantly greater im- postoperative exercise should consider patient-specific goals
provements in the 6MW distance (p ¼ 0.029), total Western in addition to having a long-term focus on strength and
Ontario and McMaster universities arthritis index (WOMAC) function.22
(p ¼ 0.007), and WOMAC pain score (p ¼ 0.001). There were
no significant differences between groups at the 1-year mark. Aquatic Therapy
Despite the success and encouraging results of the IFR group, Aquatic therapy after TKA has recently gained popularity, as it
they were unable to attain the same level of functional ability is believed that the buoyancy of water attenuates the effects of
as healthy age-matched individuals. By 12 months, only 30 of gravity, decreasing shear, and compressive forces in joints.40
69 patients (43.5%) who completed the study had a 6MW In addition, the water resistance improves strength, particu-
performance within normal ranges (mean, 448 m; 95% confi- larly as its intrinsic property to resist movements increases
dence interval, 423–473 m), of which 20 received IFR training. with speed.21,41 This may be more advantageous in the early

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Evgeniadis et al27 investigated the effects of a preoperative postoperative phase when patients are limited by pain, and
or postoperative rehabilitation program for patients before fortunately these therapy programs can begin anywhere from
and after primary TKA. A total of 72 patients were random- 4 days to 18 months after TKA.40 Aquatic exercises may
ized into three groups; a control group, a group that received include ROM stretches for the hip, knee, and ankle; single
3 weeks of preoperative strengthening exercises with a focus leg balance, mini-squats, cycle kicks, and leg swings.40,42
on the core and upper extremities, and a group that received Valtonen et al40 conducted a RCT to study the effects of
8 weeks of home-supervised rehabilitation for the lower aquatic resistance training on mobility, muscle power, and
extremity. Subjects in all three groups received standard cross-sectional area (CSA). A total of 50 patients were
inpatient rehabilitation that lasted 12 to 14 days. Parameters randomly assigned to either a 12-week progressive aquatic
measured were functional ability (using the Iowa level of resistance-training program (n ¼ 26) or were advised to
assistance scale) and active ROM of the knee at the 10th and maintain their usual level of activity (n ¼ 24). At the end of
14th weeks after TKA. At 10 weeks after surgery, patients in 12 weeks, the average rate of perceived exertion was esti-
the postoperative exercise group demonstrated greater flex- mated to be 17 (0 ¼ no effort; 20 ¼ maximum effort) in six
ion (p < 0.01), extension (p < 0.01), and functional ability patients in the aquatic training group. Patients in the aquatic
(p < 0.001) compared with the control and preoperative training group increased their habitual walking speed by 9%
groups. At 14 weeks after surgery, the postoperative exercise (p ¼ 0.005) and decreased their SCT by 15% (p ¼ 0.006). This
group continued to have significantly greater knee ROM group also increased knee flexor and extensor power in the
(p < 0.01 for both flexion and extension) compared with operated leg by 48% (p ¼ 0.003) and 32% (p < 0.001), respec-
the two other groups. Although ROM was effectively in- tively. The mean thigh muscle CSA in the experimental group
creased in this group, they were only able to achieve 98.42 increased by a mean of 3% (p ¼ 0.018) in the operated leg and
and 0.8 degrees of flexion and extension, respectively. 2% (p ¼ 0.019) in the nonoperated leg compared with con-
Previous studies have indicated that restoration of at least trols. There were no differences in the WOMAC scores
110 degrees of knee flexion is necessary for satisfactory between groups. However, significant changes were lost at
function and to complete most daily activities.28–30 Knee 1-year follow-up, which may indicate the importance of
flexion contractures resulting in ROM reduction occur in 1 continuing aquatic rehabilitation strategies over the long-
to 15% of primary TKA patients and can cause significant term to prevent the loss of training-induced benefits.43
functional limitations.31,32 In a study conducted at the au- Conversely, Harmer et al44 randomized 102 patients after
thor’s institution,33 47 patients with knee flexion contrac- TKA to participate in a 6-week land-based (n ¼ 49) or water-
tures (mean, 22 degrees; range, 10–40 degrees) after primary based (n ¼ 53) exercise program. Patients in both groups
or revision TKA were treated with a custom knee device in were assessed by the same examiner starting from 2 weeks
supervised therapy sessions. After a mean treatment time of after surgery (baseline) and at 8 and 26 weeks after surgery.
9 weeks (range, 6–16 weeks), 27 of 29 patients who received While both training groups improved significantly from
primary TKAs achieved full extension, which was preserved baseline, no differences were noted between groups with
at an 18-month follow-up. In all patients, knee society knee respect to WOMAC score, knee ROM, 6MW, and SCT.
scores and functional scores improved from 50 to 91 points In summary, some studies have demonstrated comparable
and 34 to 89 points, respectively. Compared with other or greater benefits with the use of aquatic therapy compared
nonoperative regimens in the literature,34–39 this knee with standard exercise programs, particularly as buoyancy

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204 Rehabilitative Guidelines after TKA Mistry et al.

decreases forces within the knee joint, which may allow recovery of TKA patients.52 It is postulated to have healing
patients to experience some relief of pain. effects on articular cartilage and ligaments, as well as shorten
hospital stay, improve ROM, and lead to fewer circulatory
Balance Training complications.52–54 With the use of CPM, the patient should
Patients often have impaired balance after TKA as a result of aim to achieve at least 0 to 90 degrees ROM upon hospital
ligamentous damage that alters mechanoreceptors. This af- discharge and 0 to 120 degrees upon completion of postop-
fects joint proprioception and postural control, which in turn erative rehab.55 Several studies have demonstrated improve-
influences knee stability.45–47 These deficits affect the ability ments with CPM use. A retrospective study conducted by
of patients to perform activities such as twisting, pivoting, Romness and Rand54 retrospectively compared patients who
walking on uneven surfaces, and changing direction. To aid received CPM post-TKA with a control group who only
with this, balance training may be employed, which includes received a bulky compression dressing. They found that the
lower extremity ROM exercises and functional task-oriented CPM group had significantly greater knee flexion at discharge
exercises with resistance bands, sidestepping, tandem walk, compared with the control group (90 vs. 88 degrees;
and use of a tilt board or balance beam.48,49 p < 0.02). Additionally, the treatment group was able to reach
In a double-blinded, RCT conducted by Piva et al,45 it was 90 degrees of flexion in 7.7 days while the control group
determined that patients who received 6 weeks of balance required 10.3 days (p < 0.001). While the CPM group had a
training in addition to their functional training demonstrated greater mean post-operative wound drainage compared with
faster gait speed and better results on a single leg balance test the control group (630 vs. 499 mL, p < 0.02), there was no
than those who only received functional training. In a pro- significant difference in the length of hospital stay after TKA.
spective RCT, Liao et al,50 randomly assigned 113 patients to McInnes et al56 also conducted a RCT comparing CPM plus
either an experimental group (n ¼ 58) that received standard standard rehabilitation to standard rehabilitation alone.

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functional training with additional balance exercises, or a At 7 days postoperatively, the CPM group had higher
control group (n ¼ 55) that received only standard functional active flexion compared with the non-CPM group (82 vs.
training. The standard functional training exercises were 75 degrees; p ¼ 0.004), as well as less swelling (p ¼ 0.0008),
based on existing protocols in the literature,26 as were the but no significant differences were observed in active and
balance exercises.48,49 Upon completion of the 8-week inter- passive extension (p > 0.05).
vention, the experimental group demonstrated significant Conversely, other studies have highlighted no significant
improvement in all categories (p < 0.001) including the advantages with the use of CPM. Pope et al57 performed a RCT
timed 10-minute walk, TUG, and WOMAC. Conversely, Fung in 53 patients, who were divided into one of three groups: no
et al,51 conducted a RCT to determine whether a gaming CPM, CPM from 0 to 40 degrees, and CPM from 0 to 70 degrees.
console (Nintendo Wii Fit, Nintendo Co., Ltd., Kyoto, Japan) At 1 year postoperatively, no significant differences were
can be used as a supplement to physiotherapy treatment in found between the groups in regards to mean flexion, func-
the recovery of balance, strength, function, and lower tional score, ROM, or fixed flexion deformity, however, it was
extremity movement following TKA. In addition to a physio- noted that patients in the CPM group required significantly
therapy session, the control group received 15 minutes of more analgesic medications (p ¼ 0.04). In addition, postop-
lower extremity and strengthening exercises while the erative blood drainage was significantly higher in the 0 to 70
experimental group received 15 minutes of game console CPM group compared with the 0 to 40 CPM (p ¼ 0.01) and no
activities that encouraged multidirectional movements. No CPM (p ¼ 0.005) groups. Similarly, Maniar et al58 evaluated
significant differences were observed in pain, knee flexion, patients who received no-CPM, 1-day CPM, or 3-day CPM
knee extension, walking speed, timed-standing tasks, lower regimes and found no statistically significant differences in
extremity functional scale, or patient satisfaction between TUG, WOMAC, short form-12, ROM, and wound healing. In
the two cohorts (p > 0.05). These results suggest that fact, knee swelling (as measured by suprapatellar girth)
application of interactive home video games that challenge decreased at a slower rate in the CPM groups as compared
balance and postural control of the lower extremities may with the control group. By day 42, the suprapatellar girth in
potentially serve as a comparable substitute to standard the control group returned to preoperative levels while
physiotherapy sessions for TKA patients. significant swelling persisted in the 1-day CPM (p ¼ 0.009)
In summary, studies have demonstrated that balance and 3-day CPM (p < 0.001) groups. Joshi et al59 also noted no
training may aid in postoperative functional recovery and significant differences in knee flexion between patients who
rehabilitation. These improvements have the potential to received only physiotherapy and patients who received CPM
restore joint proprioception and postural control. While there and physiotherapy at 6 weeks (p ¼ 0.69) or 3 months
are various ways to supplement post-TKA rehabilitation with (p ¼ 0.41). While both groups individually demonstrated
balance training, there are no clear protocols on the use of significant improvement in WOMAC score at 6 weeks (both
these exercises. groups p < 0.01) and three months (both groups p < 0.01),
there were no significant between-group differences in their
Continuous Passive Motion scores at those times (p ¼ 0.41 and 0.18, respectively). Mau-
Continuous passive motion (CPM) is a machine that repeat- Moeller et al55 evaluated the effect of CPM and a new sling
edly provides passive movement of the knee joint through a exercise training program (ST) on clinical and functional
controlled ROM and has been a staple modality in the outcomes after TKA. Patients in the CPM group received

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 Rehabilitative Guidelines after TKA Mistry et al. 205

physiotherapy and CPM application while the ST group ic compared with the control group (509 vs. 680 mg mor-
received physiotherapy and performed sling exercises. phine equivalents) during the same period (p < 0.05).
Patients in the ST group demonstrated significantly higher Treatment group patients also reported greater satisfaction,
passive flexion ROM by 6 degrees compared with the CPM with regards to pain control and stiffness relief, than the
group 1 day before discharge (p ¼ 0.022), however, no differ- control group (p < 0.0001).
ence was documented at the 3-month follow-up visit. Given In contrast, Bech et al64 found no additional benefit of
the ease at which sling therapy can be performed and its cost- consistent cooling via a motorized icing device in comparison
effectiveness compared with CPM, further research is to intermittent cooling using an ice bag within the first
warranted to assess its value and degree of clinical outcomes 48 hours after TKA. Significant differences were not observed
as a modality of post-TKA rehabilitation. between the control and intervention groups with regards to
In summary, CPM has been a long-standing approach pain, nausea or vomiting, passive ROM, or opioid use despite
utilized in the recovery of TKA patients. While some may significant differences in patient-reported satisfaction and
argue for the benefits of CPM in the acute in-patient phase, its compliance. The intervention group demonstrated greater
degree of long-term advantage still remains controversial.59 satisfaction (8.4 vs. 6.0, p ¼ 0.002) and greater compliance
More recent literature has suggested that CPM use may be both at day and night (86 vs. 30% and 88 vs. 31%, respectively;
associated with increased postoperative blood drainage, in- p < 0.001 for both), which the authors suggest may be due to
creased analgesic use, and persistent swelling. As a result of the convenience and ease of using an automated device.
this new evidence, orthopedists should assess if CPM use will In summary, most studies suggest that cryopneumatic
have a positive impact on patient recovery. therapy is effective for postoperative pain relief and function,
particularly as it decreases the metabolic activity of local
Cold Therapy and Compression tissues while providing external support and limiting the

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The use of cold and compressive therapy has been tradition- accumulation of soft-tissue swelling.62 However, the exact
ally implemented after TKA to mitigate pain, swelling, and routine of postoperative application may differ from surgeon
inflammation of the affected joint. Cold therapy, or cryother- to surgeon.
apy, slows the enzymatic function and induces vasoconstric-
tion of the perioperative tissues.60 It also reduces leukocyte Neuromuscular Electrical Stimulation
migration and attenuates nerve signal transmission, produc- NMES is a noninvasive modality that employs the use of dosed
ing a temporary anesthetic and analgesic effect.61 Studies electrical currents delivered through cutaneous electrode
have demonstrated a positive correlation between local pads to stimulate muscle contraction.65 It may have the
temperature and synovial prostaglandin E2, a known marker potential to augment muscle strength and functional perfor-
of pain and inflammation.62 External compression is thought mance, by overriding deficits in muscle activation caused by
to prevent edema by increasing interstitial pressure and central nervous system impairments.66–69 It is thought to
reducing the flow of fluid into the interstitial space. In recruit a greater proportion of type II fast-twitch muscle
addition to providing soft-tissue support, compressive dress- fibers, which generates higher levels of force production
ings can limit the volume of the intra-articular space, reduc- and may correspond to better functional performance and
ing the accumulation of hemarthroses.60,63 recovery.65,69–73 This is particularly important as failure of
Levy and Marmar60 conducted a prospective RCT compar- voluntary quadriceps muscle activation is a major source of
ing post-TKA patients who received cold compressive dress- weakness and can result from either an inability to utilize all
ings to a control cohort who received dressings alone (gauze available motor units or a reduction in the peak motor unit
pads [Webril, Covidien, Dublin, Ireland, and Ace bandage discharge rate from the recruited units.74 Voluntary quadri-
[Hemovac Zimmer Biomet, Warsaw, Indiana]). By postopera- ceps activation deficit can result from swelling, joint damage,
tive day (POD) 3, patients in the treatment group demon- and pain, and has been linked to decreased gait speed,
strated significantly less blood loss (548 vs. 807 mL as increased SCTs, impaired balance, and an increased risk of
measured by Hemovac output) and a significantly smaller falls.75–78 As a result, devices such as NMES have been
net hemoglobin drop (3.1 vs. 4.7 mg) (p < 0.001 for both) investigated in the use of post-TKA muscle weakness.
compared with the control group. Additionally, the cold In a prospective longitudinal RCT, Stevens-Lapsley et al79
compression group used less morphine per kilogram per 48 compared the efficacy of combined quadriceps NMES and
hours (p < 0.005) and demonstrated better visual analog standard rehabilitation (n ¼ 35) with standard rehabilitation
scale (VAS) scores during PODs 1 to 3 (p < 0.01 for POD 2, alone (n ¼ 31) following TKA. The intervention group initiat-
and p < 0.05 for POD 3). They also had a significantly greater ed NMES on POD 2 and received 15 contractions twice daily
total arc ROM in comparison to the control group on POD 7 for a total of 6 weeks. At 3.5 weeks postoperatively, the NMES
(p < 0.05) and POD 14 (p < 0.01). Similarly, Su et al63 ran- group had significantly better quadriceps strength
domized 280 patients to either a treatment group that (p < 0.001), hamstring strength (p ¼ 0.04), 6MW
received a cryopneumatic device, or a control group that (p < 0.001), SCT (p ¼ 0.001), TUG (p ¼ 0.003), and extension
received ice with static compression. While neither group active ROM (p ¼ 0.01) compared with the control group, and
exhibited any significant difference in ROM, 6MW, TUG, or these improvements were maintained at 12 months
knee girth compared with each other, postoperatively, the (p < 0.05). Compared with baseline, the quadriceps strength
treatment group used a significantly lower amount of narcot- of the NMES group at 12 months improved 11% more than

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206 Rehabilitative Guidelines after TKA Mistry et al.

that of the control group (p < 0.05). Moreover, the NMES required less pharmacological pain control (p ¼ 0.05).
group demonstrated significantly better 12-month outcomes Despite these promising results, the authors did not compare
for hamstring strength, SCT, TUG, and 6MW (p < 0.05 for all). pharmaceutical use between the placebo TENS and actual
Avramidis et al80 conducted a similar prospective RCT evalu- TENS groups. Similarly, Rakel et al82 conducted a randomized
ating 70 patients who received either NMES and physiother- placebo control trial that separated patients into cohorts
apy or physiotherapy alone. Compared with the control receiving TENS (n ¼ 122), placebo TENS (n ¼ 123), or the
group, the NMES group demonstrated a significantly greater standard of care (n ¼ 72). It was observed that the supple-
improvement in walking speed for the 3-minute walk test at mentation of TENS with pharmacological pain control re-
6 weeks (p ¼ 0.003) and 3 months (p ¼ 0.001), however, this sulted in a significant reduction of pain during movement
difference was not maintained at 12 months. The NMES group (p ¼ 0.019) and during gait speed testing (p ¼ 0.006) com-
also had significantly greater short form-36 (SF-36) physical pared with the standard of care group.
component scores and knee society function scores at Conversely, there are studies suggesting that TENS has no
6 weeks, 3 months, and 1 year after TKA (p ¼ 0.001 for all). effect on pain relief. In a double blinded, placebo controlled
Conversely, there is evidence suggesting that NMES offers trial, Breit et al89 randomized patients to receive patient-
no significant benefit in post-TKA patients. In the previously controlled analgesia (PCA, n ¼ 22), PCA and TENS (n ¼ 25), or
mentioned study by Petterson et al,25 no significant differ- PCA and placebo TENS (n ¼ 22). There were no significant
ences were found in any of the assessed outcomes (strength, differences in the use of sedation, spinal anesthesia, or
SF-36 physical and mental, or performance based tests; morphine, or VAS scores between the three groups
p > 0.08 for all after adjusted for baseline values) between (p > 0.05). Furthermore, Angulo et al90 evaluated patients
the progressive strength training group (n ¼ 45) and the who received sensory threshold TENS (n ¼ 18), subthreshold
joint NMES-progressive strength training group (n ¼ 47). In TENS (n ¼ 18), or no TENS at all (control, n ¼ 12). All three

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a single-center, RCT comparing NMES paired with at-home groups received CPM during their hospitalization. Although
ROM exercises to therapist-managed physical therapy, Lev- the two cohorts receiving TENS had improved VAS scores
ine et al81 observed noninferiority at 6 months for all during POD 1 to 3, there were no significant differences
parameters (flexion, extension, knee society score pain/ between groups for pain relief, hospital stay, knee flexion
function, WOMAC, TUG). Despite these reports suggesting arc, or narcotic dosage (p > 0.05 for all). This suggests that the
no long-term advantage of NMES use, it is worth noting that use of TENS may provide only subjective pain relief.
they highlight the benefits of early NMES. The time course for In summary, as a pain relief modality, TENS has been
initiating NMES as well as its frequency of application vary gaining popularity among patients despite the presence of
from study to study, and therefore, may explain differences in contradictory results in the literature. Its exact mechanism of
findings. analgesia is more complex than we currently understand,
In summary, patients who are unable to voluntarily acti- however, its ease of use and potential for facilitating func-
vate the quadriceps muscle immediately after TKA may tional recovery warrant further trials.
benefit from early intervention with NMES. It can be easily
administered following basic instruction and has the poten- Instrument-Assisted Soft-Tissue Therapy
tial to mitigate loss of quadriceps strength. Differences in the Instrument-assisted soft-tissue therapy, specifically Astym
design of NMES protocols may result in conflicting findings. therapy (Performance Dynamics, Muncie, IN), is a noninva-
Further research is needed to determine specific parameters sive technique aimed to stimulate soft-tissue regeneration
of NMES, such as duration, timing, and intensity, and to also through the application of pressure to the affected area.91 In
establish its long-term impact on patient outcomes. theory, this aids in fibroblast recruitment and activation from
dysfunctional capillaries, which stimulates the endogenous
Transcutaneous Electrical Nerve Stimulation release of growth factors and cellular mediators, leading to
TENS is a device where adhesive electrodes are placed on the fibrotic resorption and tissue regeneration.92,93 In vivo stud-
skin, sending controlled electrical impulses to local sensory ies in rats have further demonstrated that fibroblast prolifer-
nerves.82 It is believed that TENS acts on central and periph- ation due to this form of treatment results in the production
eral nervous system mechanisms to promote an analgesic of fibronectin, an important component in cellular signaling
effect.83 Specifically, it is thought to activate endogenous for normal collagen organization, extracellular matrix forma-
opioid receptors in the spinal cord and brainstem, triggering tion, and soft-tissue healing.91,94,95 This technique has been
inhibitory centers to decrease sensitivity of the central used for the treatment of post-TKA stiffness, which is a
nervous system.84–87 As pharmacological measures do not debilitating complication that may lead to decreased ROM,
always provide adequate pain relief during rehabilitation, activity limitations, and constant pain in up to 15% of the
these devices have been considered as an alternative analge- patients.31,32,96,97
sic modality. The standardized process for this treatment method in-
Stabile and Mallory88 prospectively evaluated the use of volves three components: (1) the assessment and treatment
placebo TENS (electrode pad placement with no current of the entire kinetic chain to address particular patterns of
applied) (n ¼ 22), actual TENS (n ¼ 43), or intramuscular fibrosis and dysfunctional soft tissue; (2) functional exercises
hydromorphone (control, n ¼ 42) in post-TKA patients, and to promote healthy, appropriate alignment of new collagen
it was observed that the placebo TENS and actual TENS group deposition capable of withstanding mechanical stresses; and

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 Rehabilitative Guidelines after TKA Mistry et al. 207

(3) detecting and minimizing inappropriate fibrosis that may normal weight patients after TKA, weight loss measures
be causing irritation or mobility restrictions.92 should still be encouraged both pre- and postoperatively.
In summary, while this modality has shown promising Obesity is often linked with other comorbidities, contrib-
results in the treatment of various chronic orthopedic uting to an increased risk for complications after TKA. These
pathologies,93,98–100 such as tendinopathy and joint pain, complications include, but are not limited to, coronary artery
evidence has yet to be published regarding its use in the disease, hypertension, diabetes mellitus, sleep apnea, and
treatment of knee joint stiffness. Further research in this hyperlipidemia.107 Optimizing patient outcomes require
area is warranted to determine its efficacy as an acceptable treatment that may need to begin before TKA. Weight loss
rehabilitation modality for post-TKA patients. At the greater than 10% of one’s body weight can reduce their risk of
author’s institution, this treatment is used on patients knee osteoarthritis to that of the nonobese population,
who cannot attain knee flexion past 90 degrees or knee thereby minimizing the need for joint arthroplasty.108 These
extension past 15 degrees. Our early results indicate that interventions, whether dietetic, pharmacological, or other-
this is a very useful modality for patients with reduced ROM wise, should persist postoperatively to reduce obese patients’
at 4 to 6 weeks postoperatively. weight in the long-term to maximize functional recovery and
implant longevity.
In summary, current studies demonstrate varying, and
Special Circumstances: Obese and Active Patients
often times, conflicting outcomes in obese TKA patients.
Obese Patients Further work is necessary to evaluate whether specific
Obesity is a well-known risk factor for knee osteoarthritis and modalities can yield better postoperative outcomes in this
may increase a patient’s susceptibility for end-stage osteoar- growing patient subpopulation.
thritis requiring TKA.101 In fact, as the prevalence of obesity

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rises as a nationwide epidemic, it stands to reason that this Active Patients
population comprises a large proportion of patients under- With advancements in surgical technique, component tech-
going TKA.102 Patients categorized as “obese” fit the widely nology, and surgeon experience, a growing number of TKAs
accepted definition of body mass index (BMI) greater than are being performed in younger patients, and many have
30,101 while others are categorized as “highly obese” and expectations to return to their full level of physical activity
“morbidly obese” if their BMIs exceed 35 and 40, following rehabilitation.109 However, specific guidelines
respectively.103 regarding return to activity of post-TKA patients remain
Numerous studies assessing outcomes of TKA in the obese unclear.
patient have demonstrated conflicting results and subse- An important factor to consider is the level of demand of
quently generated much controversy regarding perioperative the activity, and whether it is low-, intermediate-, or high-
risks, implant longevity, complications, and outcomes. impact. As such, patients should address their particular
Samson et al104 conducted a literature review evaluating interests with their surgeons to determine the best recom-
TKA in patients with BMI > 40. In the eight comparative mendation. Generally, most orthopedists recommend
studies that were examined, patients experienced overall conservative, low-impact activities such as cycling, walking,
improvements in outcome measures postoperatively, how- swimming, and golf.110,111 Higher impact activities, such as
ever, higher complication rates were observed in all morbidly football, basketball, and soccer are usually discouraged
obese groups. These patients had a greater prevalence of deep because orthopedists are concerned that an increased joint
periprosthetic infections (3–9 times higher) and wound load may cause accelerated implant wear and debris forma-
complications. Amin et al105 compared the results of 41 tion, leading to periprosthetic osteolysis and prosthetic fail-
morbidly obese patients (BMI > 40) with that of a matched ure.112,113 However, there is no consensus for many activities,
cohort of 41 nonobese patients (BMI < 30) after TKA. At less such as power walking, hiking, tennis, or jogging.110
than 4 years after surgery, the morbidly obese group exhib- Several studies have shown that activity levels after TKA do
ited worse results compared with the nonobese group, as not negatively impact outcomes. Jones et al114 conducted a
demonstrated by inferior knee society scores (mean knee case–control study examining 26 patients with primary TKAs
score 85.7 vs. 90.5, respectively, p ¼ 0.08; mean function followed by revisions compared with 26 patients with TKAs
score 75.6 vs. 83.4, p ¼ 0.01), higher incidence of radiolucent who did not undergo revision. It was noted that both groups
lines on postoperative radiographs (29 vs. 7%, p ¼ 0.02), engaged in low-impact activities. They determined that
higher rate of complications (32 vs. 0%, p ¼ 0.001), and physical activity is not a risk factor for revision TKA, and
inferior survivorship using revision and pain as endpoints that patients should be encouraged to maintain activity levels
(72.3 vs. 97.6%, p ¼ 0.002). Hamoui et al106 demonstrated following TKA. Mont et al115 conducted a midterm follow-up
that moderate obesity, defined as BMI 30 to 35, has no effect study comparing clinical and radiographic outcomes of 50
on the clinical and radiological outcome after TKA. Compared patients engaged in at least 4 years of high-impact activity
with patients with BMI > 30, there was no statistical signifi- with an age- and sex-matched cohort of 50 sedentary
cance with regards to median knee society scores, presence of patients. The high-impact activities in this study included
radiolucent areas, evidence of osteolysis, revision rates, and tennis, golf, skiing, and cycling or jogging. At a mean 7-year
patient survival. The authors acknowledge that while their follow-up, each group demonstrated one clinical failure, two
results in moderately obese patients were similar to those of revisions, and no progressive radiolucencies. The authors

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208 Rehabilitative Guidelines after TKA Mistry et al.

concluded there was no difference in outcome as a result of consideration. Our review aimed to address both of
high-impact activities. these issues.
Contrarily, studies have demonstrated unfavorable results Based on the evidence examined, the optimal rehabilita-
with high levels of activity. Lavernia et al116 conducted a tion protocol should include several crucial components.
study examining autopsy-retrieved specimens after TKA, and Patients should engage in strengthening and functional
observed a positive correlation between activity level, poly- exercises that progress as clinical milestones are met over
ethylene component wear rate, and length of prosthesis the first 8 weeks after TKA. Careful early mobilization of the
implantation. Another study by Mintz et al117 evaluated tibial patella in all directions is critical for optimal ROM. Rehabili-
polyethylene in 33 patients after TKA, where component tation is encouraged to begin as soon as the first POD.
failure was more notably observed in younger patients. Strengthening programs can begin as closed-chain quadri-
They suggested this association was likely due to patient ceps exercises with supplemental weight added, and eventu-
activity level. ally progress to include eccentric and isokinetic exercises that
The amount of experience a patient has in a recreational are performed in concentric and eccentric modes throughout
activity is also important to consider during rehabilitation, the entire knee ROM. Goals should include an emphasis on
particularly for physically demanding activities with a risk for improvement of functional independence and mobility, nor-
injury, such as skiing, hiking, or horseback riding.110 It has malization of gait mechanics, pain reduction, and attainment
been proposed that individuals who are not regularly active, of early ROM.21,22,33 We agree with the research by Ebert
and therefore inadequately prepared for sporting activity, are et al119 that suggests active knee flexion of 80 degrees at the
at higher risk for athletic injury.118 Additionally, the knee initial outpatient visit (1–2 weeks post-TKA) is strongly
joint in a beginner may experience greater loads as compared correlated with active knee flexion of 110 degrees at 7 to
with someone who is at a more advanced level.111 In beginner 8 weeks after TKA. The achievement of 110 degrees of knee

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skiers, it was found that the knee joint forces were 7,463 N flexion has been shown to provide a satisfactory function for
during the steering phase while veteran skiers experienced most patients to complete most activities of daily living. This
considerably lesser knee joint forces of 2,775 N. knee flexion guideline may allow for the administration of a
In summary, rehabilitation in younger, more active more focused and individualized rehabilitation. As a result,
patients is often aimed toward resuming athletic participa- patients may gain a better understanding of realistic goals of
tion. While patients should be encouraged to remain physi- progression throughout the early stages of therapy, while
cally active following TKA, they should initially be limited to practitioners may be able to simultaneously identify patients
lower-impact activities of shorter duration. Patients should at high risk for poor long-term outcomes who may benefit
focus on achieving fundamental functions of their lower from additional intervention. Additionally, the SAFTE proto-
extremities before advancing, in an effort to decrease chances col should be considered as a part of the patients’ physical
of injury. Moreover, physicians should account for patients’ therapy regimen.24 Balance training may also be supple-
baseline and expected postoperative activity levels when mented into therapy sessions in an effort to restore joint
planning a rehabilitation exercise program. proprioception and postural control.50 Providers can consider
recommending aquatic therapy to engage patient participa-
tion while regaining strength and relieving pain.40 Rehabili-
Recommendations
tation sessions should be initially supervised and eventually
A major objective of this review was to propose a set of transform into the patient’s responsibility at home. Regular
guidelines for patient return to activity or sport after TKA. It guidance and progression should be provided to ensure
should be noted that previous authors have attempted to proper utilization of home exercises.
provide suggestions, as well. A report by Pozzi et al21 Cryopneumatic therapy via intermittent ice pack and
reviewed the current literature and highlighted the benefit compression should be provided at the end of each therapy
of supervised therapy sessions using combined modalities session due to its positive effects on inflammation, edema,
that progress in intensity based on the patient’s progress. and pain relief.60 Patients expressing concern with excessive
The strengths of this review lie in their inclusion of several narcotic usage can be offered an automatic cryopneumatic
rehabilitative modalities such as strengthening, aquatic device rather than ice and static compression. We recom-
therapy, balance training, and the importance of clinical mend the use of sling therapy over CPM, as it provides similar,
environment. In another review, Westby et al22 examined if not better results and is more cost-effective.55 The use of
the available literature for therapy after TKA and outlined NMES in addition to progressive strengthening exercises has
the advantages of structured, supervised rehabilitation. shown promising results and should be provided to attenuate
Strengths of this report are that they included survey the early loss of quadriceps strength after TKA.25,79 The ability
results from two expert panels to determine the best of NMES to recruit of additional type II (fast-twitch) muscle
practices, and that they provide recommendations of out- fibers enables greater force generation, assisting in rehabili-
come measures to routinely assess (functional, satisfaction, tation and functional performance. TENS is not recommended
quality of life, etc.). However, both reviews are limited in as a solo therapy, however, we recommend its use as an
that they do not encompass all available rehabilitative adjunct to other pain management modalities. Adequate
modalities, and they do not discuss recommendations for pain control can help facilitate early patient participation in
specific “subsets” of growing populations that warrant recovery, which may ultimately lead to better functional

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 Rehabilitative Guidelines after TKA Mistry et al. 209

outcomes. Preliminary studies92,99,100 have demonstrated with total knee arthroplasty. J Arthroplasty 2014;29(7):
promising results on the use of instrument-assisted soft- 1499–1502
tissue therapy for several chronic orthopedic diseases, how- 10 Doerfler D, Gurney B, Mermier C, Rauh M, Black L, Andrews R.
High-velocity quadriceps exercises compared to slow-velocity
ever, further prospective evaluations are needed to assess its
quadriceps exercises following total knee arthroplasty: a ran-
utility as a rehabilitation technique for knee stiffness follow- domized clinical study. J Geriatr Phys Ther 2015; doi: 10.1519/
ing TKA. JPT.0000000000000071
All physicians should encourage healthy forms of weight 11 Thomas AC, Judd DL, Davidson BS, Eckhoff DG, Stevens-Lapsley JE.
loss in obese patients (BMI > 30) to reduce risk of osteoar- Quadriceps/hamstrings co-activation increases early after total
knee arthroplasty. Knee 2014;21(6):1115–1119
thritis and its progression. Regardless of preoperative or
12 Yoshida Y, Mizner RL, Snyder-Mackler L. Association between
postoperative status, providers have a responsibility to coun-
long-term quadriceps weakness and early walking muscle co-
sel patients to pursue a sustainable, healthy, and active contraction after total knee arthroplasty. Knee 2013;20(6):
lifestyle.106 426–431
In regards to activity, emphasis should be placed on 13 Stevens-Lapsley JE, Balter JE, Kohrt WM, Eckhoff DG. Quadriceps
fundamental rehabilitative modalities before resumption of and hamstrings muscle dysfunction after total knee arthroplasty.
Clin Orthop Relat Res 2010;468(9):2460–2468
higher demand activity. Enthusiastic patients may be eager to
14 Ardali G. A daily adjustable progressive resistance exercise pro-
return to activity, but should be educated on the risks and tocol and functional training to increase quadriceps muscle
precautions before proceeding. Low-impact activities such as strength and functional performance in an elderly homebound
walking, swimming, and stationary bicycling can be encour- patient following a total knee arthroplasty. Physiother Theory
aged, but patients should consult with their surgeons before Pract 2014;30(4):287–297
engaging in higher impact activities. 15 Meier W, Mizner RL, Marcus RL, Dibble LE, Peters C, Lastayo PC.
Total knee arthroplasty: muscle impairments, functional limita-

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tions, and recommended rehabilitation approaches. J Orthop
Conclusion Sports Phys Ther 2008;38(5):246–256
16 Brander VA, Stulberg SD, Chang RW. Life after total hip arthro-
In conclusion, recovery of strength and ROM after TKA can be plasty. Bull Rheum Dis 1993;42(3):1–5
achieved by a combination of modalities. Not all forms of 17 Taniguchi M, Sawano S, Kugo M, Maegawa S, Kawasaki T, Ichiha-
shi N. Physical activity promotes gait improvement in patients
rehabilitation may apply to every patient who undergoes
with total knee arthroplasty. J Arthroplasty 2015 (e-pub ahead of
TKA, given the potential presence of additional comorbidities.
print). doi: 10.1016/j.arth.2015.11.012
The importance of joint strengthening and gradual introduc- 18 Peter WF, Nelissen RG, Vlieland TP. Guideline recommendations
tion to a more active lifestyle cannot be overemphasized. for post-acute postoperative physiotherapy in total hip and knee
Proper instruction and commitment to rehabilitation can arthroplasty: are they used in daily clinical practice? Musculos-
potentially help patients achieve, or even surpass, their kelet Care 2014;12(3):125–131
19 Brander V, Stulberg SD. Rehabilitation after hip- and knee-joint
preoperative activity levels.
replacement. An experience- and evidence-based approach to
care. Am J Phys Med Rehabil 2006;85(11, Suppl):S98–S118, quiz
S119–S123
20 Bade MJ, Stevens-Lapsley JE. Restoration of physical function in
References patients following total knee arthroplasty: an update on rehabil-
1 Kurtz SM, Ong KL, Schmier J, et al. Future clinical and economic itation practices. Curr Opin Rheumatol 2012;24(2):208–214
impact of revision total hip and knee arthroplasty. J Bone Joint 21 Pozzi F, Snyder-Mackler L, Zeni J. Physical exercise after knee
Surg Am 2007;89(Suppl 3):144–151 arthroplasty: a systematic review of controlled trials. Eur J Phys
2 Bade MJ, Kohrt WM, Stevens-Lapsley JE. Outcomes before and Rehabil Med 2013;49(6):877–892
after total knee arthroplasty compared to healthy adults. J Orthop 22 Westby MD, Brittain A, Backman CL. Expert consensus on best
Sports Phys Ther 2010;40(9):559–567 practices for post-acute rehabilitation after total hip and knee
3 Barrack RL, Ruh EL, Chen J, et al. Impact of socioeconomic factors arthroplasty: a Canada and United States Delphi study. Arthritis
on outcome of total knee arthroplasty. Clin Orthop Relat Res Care Res (Hoboken) 2014;66(3):411–423
2014;472(1):86–97 23 Bade MJ, Stevens-Lapsley JE. Early high-intensity rehabilitation
4 Ibrahim MS, Alazzawi S, Nizam I, Haddad FS. An evidence-based following total knee arthroplasty improves outcomes. J Orthop
review of enhanced recovery interventions in knee replacement Sports Phys Ther 2011;41(12):932–941
surgery. Ann R Coll Surg Engl 2013;95(6):386–389 24 Kolisek FR, Gilmore KJ, Peterson EK. Slide and flex, tighten, extend
5 Rubin LE, Murgo KT. Brief report: total knee arthroplasty per- (SAFTE): a safe, convenient, effective, and no-cost approach to
formed with patient-specific, pre-operative CT-guided naviga- rehabilitation after total knee arthroplasty. J Arthroplasty 2000;
tion. R I Med J (2013) 2013;96(3):34–37 15(8):1013–1016
6 Stiehl JB, Heck DA. How precise is computer-navigated gap 25 Petterson SC, Mizner RL, Stevens JE, et al. Improved function from
assessment in TKA? Clin Orthop Relat Res 2015;473(1):115–118 progressive strengthening interventions after total knee arthro-
7 Banerjee S, Cherian JJ, Elmallah RK, Jauregui JJ, Pierce TP, Mont plasty: a randomized clinical trial with an imbedded prospective
MA. Robotic-assisted knee arthroplasty. Expert Rev Med Devices cohort. Arthritis Rheum 2009;61(2):174–183
2015;12(6):727–735 26 Moffet H, Collet JP, Shapiro SH, Paradis G, Marquis F, Roy L.
8 Mizner RL, Petterson SC, Stevens JE, Vandenborne K, Snyder-Mackler Effectiveness of intensive rehabilitation on functional ability
L. Early quadriceps strength loss after total knee arthroplasty. The and quality of life after first total knee arthroplasty: A single-
contributions of muscle atrophy and failure of voluntary muscle blind randomized controlled trial. Arch Phys Med Rehabil 2004;
activation. J Bone Joint Surg Am 2005;87(5):1047–1053 85(4):546–556
9 Bjerke J, Öhberg F, Nilsson KG, Stensdotter AK. Compensatory 27 Evgeniadis G, Beneka A, Malliou P, et al. Effects of pre- or
strategies for muscle weakness during stair ascent in subjects postoperative therapeutic exercise on the quality of life, before

The Journal of Knee Surgery Vol. 29 No. 3/2016

210 Rehabilitative Guidelines after TKA Mistry et al.

and after total knee arthroplasty for osteoarthritis. J Back Mus- 47 Solomonow M, Krogsgaard M. Sensorimotor control of
culoskeletal Rehabil 2008;21:161–169 knee stability. A review. Scand J Med Sci Sports 2001;11(2):
28 Devers BN, Conditt MA, Jamieson ML, Driscoll MD, Noble PC, 64–80
Parsley BS. Does greater knee flexion increase patient function 48 Fitzgerald GK, Childs JD, Ridge TM, Irrgang JJ. Agility and pertur-
and satisfaction after total knee arthroplasty? J Arthroplasty bation training for a physically active individual with knee
2011;26(2):178–186 osteoarthritis. Phys Ther 2002;82(4):372–382
29 Rowe PJ, Myles CM, Walker C, Nutton R. Knee joint kinematics in 49 Gstoettner M, Raschner C, Dirnberger E, Leimser H, Krismer M.
gait and other functional activities measured using flexible Preoperative proprioceptive training in patients with total knee
electrogoniometry: how much knee motion is sufficient for arthroplasty. Knee 2011;18(4):265–270
normal daily life? Gait Posture 2000;12(2):143–155 50 Liao CD, Liou TH, Huang YY, Huang YC. Effects of balance training
30 Tew M, Forster IW, Wallace WA. Effect of total knee arthroplasty on functional outcome after total knee replacement in patients
on maximal flexion. Clin Orthop Relat Res 1989;(247):168–174 with knee osteoarthritis: a randomized controlled trial. Clin
31 Kim J, Nelson CL, Lotke PA. Stiffness after total knee arthroplasty. Rehabil 2013;27(8):697–709
Prevalence of the complication and outcomes of revision. J Bone 51 Fung V, Ho A, Shaffer J, Chung E, Gomez M. Use of Nintendo Wii
Joint Surg Am 2004;86-A(7):1479–1484 Fit™ in the rehabilitation of outpatients following total knee
32 Maloney WJ. The stiff total knee arthroplasty: evaluation and replacement: a preliminary randomised controlled trial. Physio-
management. J Arthroplasty 2002;17(4, Suppl 1):71–73 therapy 2012;98(3):183–188
33 McGrath MS, Mont MA, Siddiqui JA, Baker E, Bhave A. Evaluation 52 Ritter MA, Gandolf VS, Holston KS. Continuous passive motion
of a custom device for the treatment of flexion contractures after versus physical therapy in total knee arthroplasty. Clin Orthop
total knee arthroplasty. Clin Orthop Relat Res 2009;467(6): Relat Res 1989;(244):239–243
1485–1492 53 Ritter MA, Stringer EA. Predictive range of motion after total knee
34 Tanzer M, Miller J. The natural history of flexion contracture in replacement. Clin Orthop Relat Res 1979;(143):115–119
total knee arthroplasty. A prospective study. Clin Orthop Relat Res 54 Romness DW, Rand JA. The role of continuous passive motion
1989;(248):129–134 following total knee arthroplasty. Clin Orthop Relat Res 1988;

Downloaded by: Universite Laval. Copyrighted material.

35 Shoji H, Solomonow M, Yoshino S, D’Ambrosia R, Dabezies E. (226):34–37
Factors affecting postoperative flexion in total knee arthroplasty. 55 Mau-Moeller A, Behrens M, Finze S, Bruhn S, Bader R, Mittelmeier
Orthopedics 1990;13(6):643–649 W. The effect of continuous passive motion and sling exercise
36 McPherson EJ, Cushner FD, Schiff CF, Friedman RJ. Natural history training on clinical and functional outcomes following total knee
of uncorrected flexion contractures following total knee arthro- arthroplasty: a randomized active-controlled clinical study.
plasty. J Arthroplasty 1994;9(5):499–502 Health Qual Life Outcomes 2014;12:68
37 Lizaur A, Marco L, Cebrian R. Preoperative factors influencing the 56 McInnes J, Larson MG, Daltroy LH, et al. A controlled evaluation of
range of movement after total knee arthroplasty for severe continuous passive motion in patients undergoing total knee
osteoarthritis. J Bone Joint Surg Br 1997;79(4):626–629 arthroplasty. JAMA 1992;268(11):1423–1428
38 Cheng K, Dashti H, McLeod G. Does flexion contracture continue 57 Pope RO, Corcoran S, McCaul K, Howie DW. Continuous passive
to improve up to five years after total knee arthroplasty? J Orthop motion after primary total knee arthroplasty. Does it offer any
Surg (Hong Kong) 2007;15(3):303–305 benefits? J Bone Joint Surg Br 1997;79(6):914–917
39 Bonutti PM, Marulanda GA, McGrath MS, Mont MA, Zywiel MG. 58 Maniar RN, Baviskar JV, Singhi T, Rathi SS. To use or not to use
Static progressive stretch improves range of motion in arthrofib- continuous passive motion post-total knee arthroplasty present-
rosis following total knee arthroplasty. Knee Surg Sports Trau- ing functional assessment results in early recovery. J Arthroplasty
matol Arthrosc 2010;18(2):194–199 2012;27(2):193–200.e1
40 Valtonen A, Pöyhönen T, Sipilä S, Heinonen A. Effects of aquatic 59 Joshi RN, White PB, Murray-Weir M, Alexiades MM, Sculco TP,
resistance training on mobility limitation and lower-limb impair- Ranawat AS. Prospective Randomized Trial of the Efficacy of
ments after knee replacement. Arch Phys Med Rehabil 2010; Continuous Passive Motion Post Total Knee Arthroplasty: Expe-
91(6):833–839 rience of the Hospital for Special Surgery. J Arthroplasty 2015;
41 Pöyhönen T, Sipilä S, Keskinen KL, Hautala A, Savolainen J, Mälkiä 30(12):2364–2369
E. Effects of aquatic resistance training on neuromuscular perfor- 60 Levy AS, Marmar E. The role of cold compression dressings in the
mance in healthy women. Med Sci Sports Exerc 2002;34(12): postoperative treatment of total knee arthroplasty. Clin Orthop
2103–2109 Relat Res 1993;(297):174–178
42 Rahmann AE, Brauer SG, Nitz JC. A specific inpatient aquatic 61 Abramson DI, Chu LS, Tuck S Jr, Lee SW, Richardson G, Levin M.
physiotherapy program improves strength after total hip or knee Effect of tissue temperatures and blood flow on motor nerve
replacement surgery: a randomized controlled trial. Arch Phys conduction velocity. JAMA 1966;198(10):1082–1088
Med Rehabil 2009;90(5):745–755 62 Stålman A, Berglund L, Dungnerc E, Arner P, Felländer-Tsai L.
43 Valtonen A, Pöyhönen T, Sipilä S, Heinonen A. Maintenance of Temperature-sensitive release of prostaglandin E2 and dimin-
aquatic training-induced benefits on mobility and lower-extrem- ished energy requirements in synovial tissue with postoperative
ity muscles among persons with unilateral knee replacement. cryotherapy: a prospective randomized study after knee arthros-
Arch Phys Med Rehabil 2011;92(12):1944–1950 copy. J Bone Joint Surg Am 2011;93(21):1961–1968
44 Harmer AR, Naylor JM, Crosbie J, Russell T. Land-based versus water- 63 Su EP, Perna M, Boettner F, et al. A prospective, multi-center,
based rehabilitation following total knee replacement: a random- randomised trial to evaluate the efficacy of a cryopneumatic
ized, single-blind trial. Arthritis Rheum 2009;61(2):184–191 device on total knee arthroplasty recovery. J Bone Joint Surg Br
45 Piva SR, Gil AB, Almeida GJ, DiGioia AM III, Levison TJ, Fitzgerald 2012;94(11, Suppl A):153–156
GK. A balance exercise program appears to improve function for 64 Bech M, Moorhen J, Cho M, Lavergne MR, Stothers K, Hoens AM.
patients with total knee arthroplasty: a randomized clinical trial. Device or ice: the effect of consistent cooling using a device
Phys Ther 2010;90(6):880–894 compared with intermittent cooling using an ice bag after total
46 Mouchnino L, Gueguen N, Blanchard C, et al. Sensori-motor knee arthroplasty. Physiother Can 2015;67(1):48–55
adaptation to knee osteoarthritis during stepping-down before 65 Sinacore DR, Delitto A, King DS, Rose SJ. Type II fiber activation
and after total knee replacement. BMC Musculoskelet Disord with electrical stimulation: a preliminary report. Phys Ther 1990;
2005;6:21 70(7):416–422

The Journal of Knee Surgery Vol. 29 No. 3/2016

 Rehabilitative Guidelines after TKA Mistry et al. 211

66 Delitto A, Snyder-Mackler L. Two theories of muscle strength transcutaneous electrical nerve stimulation (TENS). J Pharmacol
augmentation using percutaneous electrical stimulation. Phys Exp Ther 2001;298(1):257–263
Ther 1990;70(3):158–164 86 Ma YT, Sluka KA. Reduction in inflammation-induced sensitiza-
67 Sisk TD, Stralka SW, Deering MB, Griffin JW. Effect of electrical tion of dorsal horn neurons by transcutaneous electrical nerve
stimulation on quadriceps strength after reconstructive surgery stimulation in anesthetized rats. Exp Brain Res 2001;137(1):
of the anterior cruciate ligament. Am J Sports Med 1987;15(3): 94–102
215–220 87 Sluka KA, Deacon M, Stibal A, Strissel S, Terpstra A. Spinal
68 Snyder-Mackler L, Delitto A, Stralka SW, Bailey SL. Use of electri- blockade of opioid receptors prevents the analgesia produced
cal stimulation to enhance recovery of quadriceps femoris muscle by TENS in arthritic rats. J Pharmacol Exp Ther 1999;289(2):
force production in patients following anterior cruciate ligament 840–846
reconstruction. Phys Ther 1994;74(10):901–907 88 Stabile ML, Mallory TH. The management of postoperative pain in
69 Stevens JE, Mizner RL, Snyder-Mackler L. Neuromuscular electri- total joint replacement: transcutaneous electrical nerve stimu-
cal stimulation for quadriceps muscle strengthening after bilat- lation is evaluated in total hip and knee patients. Orthop Rev
eral total knee arthroplasty: a case series. J Orthop Sports Phys 1978;7:121–123
Ther 2004;34(1):21–29 89 Breit R, Van der Wall H. Transcutaneous electrical nerve stimula-
70 Binder-Macleod SA, Halden EE, Jungles KA. Effects of stimulation tion for postoperative pain relief after total knee arthroplasty.
intensity on the physiological responses of human motor units. J Arthroplasty 2004;19(1):45–48
Med Sci Sports Exerc 1995;27(4):556–565 90 Angulo DL, Colwell CW. Use of Postoperative TENS and Continu-
71 Cabric M, Appell HJ, Resic A. Fine structural changes in electro- ous Passive Motion Following Total Knee Replacement. J Orthop
stimulated human skeletal muscle. Evidence for predominant Sports Phys Ther 1990;11(12):599–604
effects on fast muscle fibres. Eur J Appl Physiol Occup Physiol 91 Hing WBR, Bremner T. Mulligan’s mobilization with movement:
1988;57(1):1–5 A systematic Review. J Manual Manip Ther 2009;17:25
72 Hainaut K, Duchateau J. Neuromuscular electrical stimulation 92 Sevier TL, Stegink-Jansen CW. Astym treatment vs. eccentric
and voluntary exercise. Sports Med 1992;14(2):100–113 exercise for lateral elbow tendinopathy: a randomized controlled

Downloaded by: Universite Laval. Copyrighted material.

73 Trimble MH, Enoka RM. Mechanisms underlying the training clinical trial. PeerJ 2015;3:e967
effects associated with neuromuscular electrical stimulation. 93 Slaven EJ, Mathers J. Management of chronic ankle pain using
Phys Ther 1991;71(4):273–280, discussion 280–282 joint mobilization and ASTYM® treatment: a case report. J
74 Kent-Braun JA, Le Blanc R. Quantitation of central activation Manual Manip Ther 2011;19(2):108–112
failure during maximal voluntary contractions in humans. Mus- 94 Davidson CJ, Ganion LR, Gehlsen GM, Verhoestra B, Roepke JE,
cle Nerve 1996;19(7):861–869 Sevier TL. Rat tendon morphologic and functional changes re-
75 Wolfson L, Judge J, Whipple R, King M. Strength is a major factor sulting from soft tissue mobilization. Med Sci Sports Exerc 1997;
in balance, gait, and the occurrence of falls. J Gerontol A Biol Sci 29(3):313–319
Med Sci 1995;50(Spec No):64–67 95 Gehlsen GM, Ganion LR, Helfst R. Fibroblast responses to variation
76 Chandler JM, Duncan PW, Kochersberger G, Studenski S. Is lower in soft tissue mobilization pressure. Med Sci Sports Exerc 1999;
extremity strength gain associated with improvement in physical 31(4):531–535
performance and disability in frail, community-dwelling elders? 96 Cerny K, Perry J, Walker JM. Adaptations during the stance phase
Arch Phys Med Rehabil 1998;79(1):24–30 of gait for simulated flexion contractures at the knee. Orthope-
77 Rantanen T, Guralnik JM, Izmirlian G, et al. Association of muscle dics 1994;17(6):501–512, discussion 512–513
strength with maximum walking speed in disabled older women. 97 Ritter MA, Lutgring JD, Davis KE, Berend ME, Pierson JL,
Am J Phys Med Rehabil 1998;77(4):299–305 Meneghini RM. The role of flexion contracture on outcomes
78 Fahrer H, Rentsch HU, Gerber NJ, Beyeler C, Hess CW, Grünig B. in primary total knee arthroplasty. J Arthroplasty 2007;22(8):
Knee effusion and reflex inhibition of the quadriceps. A bar to 1092–1096
effective retraining. J Bone Joint Surg Br 1988;70(4):635–638 98 McCormack JR. The management of bilateral high hamstring
79 Stevens-Lapsley JE, Balter JE, Wolfe P, Eckhoff DG, Kohrt WM. tendinopathy with ASTYM® treatment and eccentric
Early neuromuscular electrical stimulation to improve quadri- exercise: a case report. J Manual Manip Ther 2012;20(3):
ceps muscle strength after total knee arthroplasty: a randomized 142–146
controlled trial. Phys Ther 2012;92(2):210–226 99 McCormack JR. The management of mid-portion achilles tendin-
80 Avramidis K, Karachalios T, Popotonasios K, Sacorafas D, Papa- opathy with astym® and eccentric exercise: a case report. Int J
thanasiades AA, Malizos KN. Does electric stimulation of the Sports Phys Ther 2012;7(6):672–677
vastus medialis muscle influence rehabilitation after total knee 100 Tyler A, Slaven E. The role of the Astym (R) process in the
replacement? Orthopedics 2011;34(3):175 management of osteoarthritis of the knee: a single-subject
81 Levine M, McElroy K, Stakich V, Cicco J. Comparing conventional research design. J Stud Phys Ther Res 2013;6:10
physical therapy rehabilitation with neuromuscular electrical 101 Böstman OM. Prevalence of obesity among patients admitted for
stimulation after TKA. Orthopedics 2013;36(3):e319–e324 elective orthopaedic surgery. Int J Obes Relat Metab Disord 1994;
82 Rakel BA, Zimmerman MB, Geasland K, et al. Transcutaneous 18(10):709–713
electrical nerve stimulation for the control of pain during reha- 102 Järvenpää J, Kettunen J, Kröger H, Miettinen H. Obesity may
bilitation after total knee arthroplasty: A randomized, blinded, impair the early outcome of total knee arthroplasty. Scand J Surg
placebo-controlled trial. Pain 2014;155(12):2599–2611 2010;99(1):45–49
83 DeSantana JM, Walsh DM, Vance C, Rakel BA, Sluka KA. Effective- 103 Miric A, Lim M, Kahn B, Rozenthal T, Bombick D, Sculco TP.
ness of transcutaneous electrical nerve stimulation for treatment Perioperative morbidity following total knee arthroplasty among
of hyperalgesia and pain. Curr Rheumatol Rep 2008;10(6): obese patients. J Knee Surg 2002;15(2):77–83
492–499 104 Samson AJ, Mercer GE, Campbell DG. Total knee replacement in
84 DeLoach LJ, Higgins MS, Caplan AB, Stiff JL. The visual analog scale the morbidly obese: a literature review. ANZ J Surg 2010;80(9):
in the immediate postoperative period: intrasubject variability 595–599
and correlation with a numeric scale. Anesth Analg 1998;86(1): 105 Amin AK, Clayton RA, Patton JT, Gaston M, Cook RE, Brenkel IJ.
102–106 Total knee replacement in morbidly obese patients. Results of a
85 Kalra A, Urban MO, Sluka KA. Blockade of opioid receptors in prospective, matched study. J Bone Joint Surg Br 2006;88(10):
rostral ventral medulla prevents antihyperalgesia produced by 1321–1326

The Journal of Knee Surgery Vol. 29 No. 3/2016

212 Rehabilitative Guidelines after TKA Mistry et al.

106 Hamoui N, Kantor S, Vince K, Crookes PF. Long-term outcome of 114 Jones DL, Cauley JA, Kriska AM, et al. Physical activity and risk of
total knee replacement: does obesity matter? Obes Surg 2006; revision total knee arthroplasty in individuals with knee osteo-
16(1):35–38 arthritis: a matched case-control study. J Rheumatol 2004;31(7):
107 Odum SM, Springer BD, Dennos AC, Fehring TK. National obesity 1384–1390
trends in total knee arthroplasty. J Arthroplasty 2013;28(8, 115 Mont MA, Mathur SK, Krackow KA, Loewy JW, Hungerford DS.
Suppl)148–151 Cementless total knee arthroplasty in obese patients. A compari-
108 Gillespie GN, Porteous AJ. Obesity and knee arthroplasty. Knee son with a matched control group. J Arthroplasty 1996;11(2):
2007;14(2):81–86 153–156
109 Healy WL, Iorio R, Lemos MJ. Athletic activity after total knee 116 Lavernia CJ, Sierra RJ, Hungerford DS, Krackow K. Activity level
arthroplasty. Clin Orthop Relat Res 2000;(380):65–71 and wear in total knee arthroplasty: a study of autopsy retrieved
110 Kuster MS. Exercise recommendations after total joint replace- specimens. J Arthroplasty 2001;16(4):446–453
ment: a review of the current literature and proposal of 117 Mintz L, Tsao AK, McCrae CR, Stulberg SD, Wright T. The arthro-
scientifically based guidelines. Sports Med 2002;32(7): scopic evaluation and characteristics of severe polyethylene wear
433–445 in total knee arthroplasty. Clin Orthop Relat Res 1991;(273):
111 Seyler TM, Mont MA, Ragland PS, Kachwala MM, Delanois RE. 215–222
Sports activity after total hip and knee arthroplasty : specific 118 Swiss Federal Office of Sports. Economic benefits of the health-
recommendations concerning tennis. Sports Med 2006;36(7): enhancing effects of physical activity: first estimates for
571–583 Switzerland: scientific position statement. Schweizerische Zeits-
112 Maloney WJ, Galante JO, Anderson M, et al. Fixation, polyethylene chrift fur Sportmedizin und Sporttraumatologie; 2001
wear, and pelvic osteolysis in primary total hip replacement. Clin 119 Ebert JR, Munsie C, Joss B. Guidelines for the early restoration of
Orthop Relat Res 1999;(369):157–164 active knee flexion after total knee arthroplasty: implications for
113 Harris WH. Wear and periprosthetic osteolysis: the problem. Clin rehabilitation and early intervention. Arch Phys Med Rehabil
Orthop Relat Res 2001;(393):66–70 2014;95(6):1135–1140

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 Appendix 1 Summary of studies examining post-TKA rehabilitation

Author, year Study group Therapy type Start of program End of program Primary measures Secondary Final
measures follow-up
Physical therapy Petterson et al, 2009 Intervention Progressive strengthening 3–4 wks postoperative 6 wks Quad strength and acti- SF-36, KOS ADLS, 12 mo
vation, TUG, SCT, 6MW knee AROM, knee
Control Standard rehabilitation N/A N/A
pain
Bade and Stevens- Intervention HI Upon hospital discharge 25 wks Pain, ROM, functional N/A 12 mo
Lapsley, 2011 performance, quadri-
Control LI 8 wks
ceps strength and
activation
Moffet et al, 2004 Intervention Intensive functional exer- 2 mo postoperatively 6–8 wks 6MW Total WOMAC, WO- 12 mo
cises þ home exercises MAC Pain
Control Usual care N/A N/A
Evgeniadis et al, Intervention A Core and upper extremity 3 wks preoperatively 12–14 d Iowa level of assistance N/A 14 wks
2008 exercises þ standard inpa- postoperatively scale, AROM
tient rehab
Intervention B Lower extremity home su- At discharge 8 wks
pervised þ standard inpa- postoperatively
tient rehab
Control Standard inpatient rehab N/A 12–14 d
postoperatively
McGrath et al, 2009 Primary TKA Custom knee device þ stan- 4–8 wks postoperatively Mean 8 wks Extension ROM, KSS N/A Mean
dard PT regimen pain/function scores 18 mo
Revision TKA
Aquatic therapy Valtonen et al, 2010 Intervention Progressive aquatic Mean 10 mo 12 wks Walking speed, SCT, N/A N/A
resistance postoperatively knee flexor/extensor
power, mean thigh
Control No intervention
muscle CSA, WOMAC
Valtonen et al, 2011 Intervention Progressive aquatic Mean 10 mo 12 wks Walking speed, SCT, N/A 12 mo
resistance postoperatively knee flexor/extensor
power, mean thigh
Control No intervention
muscle CSA, WOMAC
Harmer et al, 2009 Intervention Water-based exercise 2 wks postoperatively 6 wks WOMAC, knee ROM, N/A 26 wks
program 6MW, stair climbing
power
Control Land-based exercise program
Balance training Piva et al, 2010 Intervention Functional training þ bal- 2–4 mo postoperatively 6 wks WOMAC, LEFS Gait speed, single leg 6 mo
ance training balance
Control Functional training
Liao et al, 2013 Intervention Functional training þ bal- N/A 8 wks Timed 10 min walk, N/A 8 wks
ance training TUG, WOMAC

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Rehabilitative Guidelines after TKA

Control Functional training

Fung et al, 2012 Intervention Standard physiotherapy Mean 37 d Mean 54 d Pain, knee flexion, knee N/A N/A

Vol. 29
þ 15 min of video games postoperatively extension, walking
speed, timed standing
Control Standard physiotherapy Mean 46 d Mean 53 d
tasks, LEFS, patient
þ 15 min lower leg postoperatively
satisfaction
strengthening

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(Continued)
213

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 214

Appendix 1 (Continued)

Author, year Study group Therapy type Start of program End of program Primary measures Secondary Final
measures follow-up
CPM Romness and Rand, Intervention PT þ CPM Immediate Mean 7.7 d Knee flexion at dis- N/A 1y
1988 postoperative charge, postoperative
Control PT þ bulky compression Mean 10.3 d
wound drainage, LoS
dressing
McInnes et al, 1992 Intervention CPM þ standard rehab Immediate 7 d for CPM Pain, active/passive Complications, LoS 6 wks

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postoperative knee ROM, swelling,
quadriceps strength
Control Standard rehab POD 1 N/A

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Pope et al, 1997 Intervention A CPM 0–40 degrees Immediate CPM removed after Mean flexion, functional N/A 12 mo
postoperative 48 h score, ROM, fixed flexion
Intervention B CPM 0–70 degrees
deformity, analgesic
Control Physiotherapy only POD 1 N/A usage

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Rehabilitative Guidelines after TKA

Maniar et al, 2012 Intervention A 1-d CPM Immediate POD 2 Pain, ROM, TUG, swell- N/A 3 mo
postoperative ing, WOMAC, SF-12,
Intervention B 3-d CPM POD 4
wound healing
Control No CPM POD 5
Joshi et al, 2015 Intervention CPM þ physiotherapy Immediate postopera- Until hospital AROM, complications, N/A 3 mo
tive for CPM; POD 1 discharge discharge disposition,
Control Physiotherapy
WOMAC
Mistry et al.

Mau-Moeller et al, Intervention Physiotherapy þ sling POD 2 1 d before discharge Passive knee flexion Active knee flexion 3 mo
2014 exercises ROM ROM, active/passive
knee extension ROM,
Control Physiotherapy þ CPM
static postural con-
trol, physical activity,
pain, LoS, SF-36, HSS,
WOMAC
Cold and compres- Levy and Marmar, Intervention Cold compressive dressings Immediate Postoperative day 14 Blood loss, change in N/A N/A
sive therapy 1993 postoperative hemoglobin, analgesic
Control Standard dressings
usage, total arc ROM
Su et al, 2012 Intervention Cryopneumatic device Immediate N/A ROM, 6MW, TUG, knee N/A 6 wks
postoperative girth, narcotic use,
Control Ice with static compression
satisfaction
Bech et al, 2015 Intervention Consistent cooling via mo- Immediate First 48 h Pain (NPRS) Nausea, vomiting, First 48 h
torized device postoperative postoperatively passive ROM, opioid postoperatively
use, patient satisfac-
Control Intermittent cooling
tion, patient
compliance
NMES Stevens-Lapsley et al, Intervention Standard rehab þ NMES Rehab on POD 1; NMES 6 wks Quadriceps strength, SF-36, WOMAC 12 mo
2012 on POD 2 hamstring strength,
6MW, SCT, TUG, exten-
Control Standard rehab POD 1 8 wks
sion active ROM
Avramidis et al, 2011 Intervention Physiotherapy þ NMES POD 2 6 wks 3-min walk test, SF-36, N/A 12 mo
KSS
Control Physiotherapy POD 1 N/A
Levine et al, 2013 Intervention Home ROM exercise þ NMES 14 d preoperative 60 d postoperative KSS pain/function, WO- N/A 6 mo
MAC, TUG
Control Therapist-managed ROM ex- N/A N/A
ercise þ strengthening
exercises

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 Appendix 1 (Continued)

Author, year Study group Therapy type Start of program End of program Primary measures Secondary Final
measures follow-up
TENS Stabile and Mallory, Intervention A Placebo TENS þ IM Immediate POD 3 Analgesic usage N/A POD 3
1978 hydromorphone postoperative
Intervention B Actual TENS þ IM
hydromorphone
Control IM hydromorphone
Rakel et al, 2014 Intervention A TENS Immediate 6 wks Pain during ROM and Pain intensity at rest, 6 wks
postoperative walking hyperalgesia,
Intervention B Placebo TENS 6 wks
function
Control Standard of care (pharmaco- N/A
logical analgesia only)
Breit et al, 2004 Intervention A PCA þ TENS Immediate First 24 h Use of sedation, spinal N/A First 24 h
postoperative postoperatively anesthesia, morphine; postoperatively
Intervention B PCA þ placebo TENS
VAS
Control PCA
Angulo et al, 1990 Intervention A Sensory threshold Immediate POD 3 VAS, pain relief, hospital N/A Either POD 3 or
TENS þ CPM postoperative stay, knee flexion arc, discharge from
narcotic usage hospital
Intervention B Subthreshold TENS þ CPM
Control CPM only

Abbreviations: 6MW, 6-min walk; ADLS, activities of daily living; AROM, active range of motion; CPM, continuous passive motion; CSA, cross-sectional area; HI, high intensity; IM, intramuscular; KOS, Knee Outcome
Survey ; KSS, knee society score; LEFS, Lower Extremity Functional Scale; LI, low intensity; LoS, length of stay; N/A, not applicable; NMES, neuromuscular electrical stimulation; POD, postoperative day; PT, physical
training; rehab, rehabilitation; ROM, range of motion; SCT, stair-climb test; SF-12, short form-12; SF-36, short form-36; TENS, transcutaneous electrical nerve stimulation; TKA, total knee arthroplasty; TUG, timed-up-
and-go test; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Arthritis Index.

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216 Rehabilitative Guidelines after TKA Mistry et al.

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Appendix 2 Physical therapy guidelines for total knee arthroplasty. (Reprinted with permission from authors and AlterG, Inc., Fremont, CA.)

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 Rehabilitative Guidelines after TKA Mistry et al. 217

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Appendix 2 (Continued )

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