J Rehabil Med 2021; 53: jrm00200

REVIEW ARTICLE

EFFECTIVENESS OF TOTAL KNEE ARTHROPLASTY REHABILITATION

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PROGRAMMES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Waleed ALRAWASHDEH, MA1, Jörg ESCHWEILER, PhD1, Filippo MIGLIORINI, MD, MBA1, Yasser EL MANSY (MD)1,3,
Markus TINGART, MD1 and Björn RATH, MD1,2
From the 1Department of Orthopedic Surgery, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany, 2Department
of Orthopedic Surgery, Klinikum Wels-Grieskirchen, Wels, Austria and 3Department of Orthopaedics and Traumatology, Alexandria
Journal of Rehabilitation Medicine

University, Alexandria, Egypt.

Objective: To investigate the effectiveness of modifi­ LAY ABSTRACT

ed rehabilitation programmes in comparison with The aim of this study was to compare modified reha-
standard rehabilitation programmes after total knee bilitation programmes with standard rehabilitation pro-
arthroplasty through randomized controlled trials. grammes after total knee replacement. A total of 18
Data sources: A search was conducted in PubMed, randomized controlled trials were included at the end
PubMed Central (PMC) and Cochrane Library data­ of the screening process. Six clinical outcomes were
bases in December 2020. used for comparison. To our knowledge, this is the first
Study selection: Randomized controlled trials were study to compare modified and standard rehabilitation
reviewed if they compared a physiotherapy exercise programmes based on the starting point and the dura-
intervention with usual or standard physiotherapy tion of each programme. The results of the comparison
care, or if they compared 2 types of exercise physio­ showed that there is no clear pattern in the combina-
therapy interventions meeting the review criteria, tion of starting time-point and duration of rehabilita-
after total knee arthroplasty for osteoarthritis. A tion that significantly improves clinical outcomes. More-
total of 18 randomized controlled trials were inclu­ over, improved clinical outcomes could not be attributed
ded at the end of the screening process. solely to any particular modification to the programmes.
Data extraction: Two authors independently screen­ Accordingly, a one-size-fits-all approach to modified
ed the literature, extracted data, and assessed the rehabilitation programmes does not result in systematic
quality of included studies. The outcomes were knee
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improvement in clinical outcome.

extension, knee flexion, pain visual analogue scale,
overall Western Ontario and McMaster Universities
worldwide incidence of TKA has increased steadily over
Osteoarthritis Index (WOMAC), 6-minute walking
test, and Timed Up and Go test.
the past 2 decades (2). The incidence of TKA in indu-
Data synthesis: There was no clear pattern regarding
strialized countries is 150–200/100,000 inhabitants (3).
which combination of starting time-point and duration After TKA, the patient’s movement is limited and
of the rehabilitation programme after total knee arthro­ restricted due to decreased muscle strength. For in-
stance, muscle function has been found to be reduced
Journal of Rehabilitation Medicine

plasty significantly improves the clinical outcome

when comparing modified rehabilitation programmes by 20–25% at one month post-TKA (4), while, after
with standard programmes. Moreover, no particular one year, it remains lower than in healthy adults,
modification to the modified programmes could be with reports of 18% slower walking speed and 51%
solely attributed to the improved clinical outcome in slower stairclimbing speed (5). Furthermore, range of
the 2 studies that showed significant improvement. motion (ROM) of the knee joint is reduced due to post-
Conclusion: Modified rehabilitation programmes do operation pain (6), haematoma and swelling (7). These
not result in systematic improvement in clinical out­ limits complete functional recovery to only 67% of
come over one-size-fits-all-approaches after total patients (8). In addition, the strength of the quadriceps
knee arthroplasty. muscle is reduced by 30.7% immediately after TKA,
Key words: rehabilitation; exercise; physical therapy; total and by 50–60% after one month, despite the initiation
knee replacement. of rehabilitation within 48 h after surgery (9).
Accepted Mar 23, 2021; Epub ahead of print Apr 13, 2021
Postoperative rehabilitation programmes are there­
fore of the highest importance, because they can
J Rehabil Med 2021; 53: jrm00200 improve function, outcome, and mobility in patients
Correspondence address: Waleed Alrawashdeh, University Hospital after TKA (10). These programmes consist of fitness
RWTH Aachen Pauwelsstraße 30, 52074 Aachen, Germany. E-mail:
waalrawashde@ukaachen.de
components comprised of exercises for joints and
muscles that include ROM, strength, walking, function,
endurance, and balance. Regaining full ROM is essen-

T otal knee arthroplasty (TKA) is an established tial to restore the natural capacity of movement that
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standard procedure to alleviate problems caused assists in regaining muscle strength by allowing full
by advanced knee osteoarthritis (OA) (1). The annual muscular contraction. Walking and functional exer­

This is an open access article under the CC BY-NC license. www.medicaljournals.se/jrm

Foundation of Rehabilitation Information doi: 10.2340/16501977-2827
 p. 2 of 12 W. Alrawashdeh et al.

cises improve blood circulation and enable the ability Selection criteria
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to perform activities of daily living, such as standing, Before beginning the systematic review and meta-analysis, a
sitting, and stair climbing, to be regained (11). Endu- protocol was written outlining the search strategy, inclusion
rance and balance exercises support the previous fitness and exclusion criteria and outcomes of interest. Eligible studies
components by increasing the duration of exercises and were chosen based on the following criteria:
stability. An increase in endurance will enable subjects • Examination of post-operative effect of the rehabilitation
programme using physical rehabilitation methods (studies
Journal of Rehabilitation Medicine

more time to exercise and to derive more benefit from using music, medication, and supporting devices, such as
exercises. Furthermore, improved balance will help knee-braces, were excluded).
patients to perform the exercises safely and smoothly, • Patients underwent unilateral or bilateral knee arthroplasty,
especially with exercises that require them to switch since both surgeries have similar rehabilitation programmes.
between legs. Regaining all these components is es- • Studies applied only to a post-operative rehabilitation pro-
gramme.
sential to reaching full recovery following a TKA. • Studies included a randomized design comparing a standard-
In the clinical setting, post-operative rehabilitation based rehabilitation programme with a patient-modified
programmes differ concerning the starting time-point and programme.
duration. Different arguments have been brought forward • Standard rehabilitation programmes must have contained at
to support the diverse approaches; however, to date, least 3 of the following 4 fitness components: strength, ROM,
function and walking.
the benefits of these approaches have not been directly • Studies calculated the mean and standard deviation (SD) of
investigated in a clinical setting. The lack of a universal the parameters the studies measured.
definition of starting time-points and duration spans adds • Studies had to be published in English language.
further complexity. Therefore, it is important to analyse
whether a particular combination of starting time-point, Quality assessment
and duration is more beneficial. Furthermore, since ad- Two authors (WA, BR) independently assessed the risk of bias
ditional methods are being incorporated into modern of the articles selected for detailed review. Methodological
rehabilitation programmes, it is worthwhile analysing domains of the assessment, namely randomization sequence,
whether these modifications improve the clinical outcome allocation concealment, blinding, and conflicts of interest were
and prognosis and, if it is the case, which methods or graded according to the PEDro scale checklist (13) .
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exercises yield the best clinical improvements.

Therefore, the aim of this systematic review and Data extraction
meta-analysis of randomized controlled studies was Two authors (WA, BR) independently extracted the data from
to evaluate the effectiveness of different modified re- the included articles in forms; previously pilot-tested for feasi-
habilitation programmes vs standard care after TKA, bility and comprehensiveness. Data were extracted from each
trial regarding participants (age, sex, group size), the content
and the effects of starting time-point and duration. of the intervention (number of sessions, tools, and tests they
used, standard care vs modified care or modified vs modified),
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setting and timing (starting point, duration), type of surgery and

METHODS outcome. When a trial employed 2 variations in rehabilitation
interventions, only one group was included (14–16).
Data sources For outcomes reported as continuous variables, mean and stan-
A search of Medline (PubMed), PubMed Central (PMC) and dard deviation were extracted. Outcomes with mean and confidence
Cochrane Library databases was conducted. Exploded MeSH interval, or medians, and interquartile ranges were excluded.
terms and keywords were used to generate sets for the follow­
ing themes: total knee arthroplasty, total knee replacement, Statistical analysis
osteoarthritis, and rehabilitation approach. The Boolean terms
“AND”, “OR” were used to find their intersection. Limitations For statistical analysis, Review Manager Software 5.3 (The
were used, including English language publications between Nordic Cochrane Collaboration, Copenhagen) was used. For
2000 and 2020 and randomized control trial. In addition, the continuous data, the inverse variance with arithmetic mean was
reference lists of all included studies were reviewed (see Appen- considered. For dichotomous data, the Mantel-Haenszel method
dix SI for complete search strategy and results). Furthermore, with odds ratio (OR) was considered. To evaluate heterogene­
the outcomes were categorized and analysed for ROM (flexion- ity, both χ2 and I-square (I2) statistical tests were performed.
extension), pain visual analogue scale (VAS), Western Ontario Value of χ2 > 0.5 along with I2 > 50% indicated heterogeneity.
and McMaster Universities Osteoarthritis Index (WOMAC) A fixed-effects model was used. If heterogeneity significantly
questionnaire, 6-minute walking test (6MWT), and Timed Up affects the comparison, a random-effects model was used. The
and Go test (TUG). Comparisons were made between outcomes confidence interval (CI) was set at 95%. Values of p < 0.05 were
in the final assessment for each group. considered statistically significant.
The review was conducted using standard methodology
outlined in the Cochrane Handbook (12) and the findings Defining the groups
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were reported according to the Preferred Reporting Items for

Systematic Reviews and Meta-Analyses (PRISMA) statement The study defined the standard programme as control group
guidelines (12). based on the description of the rehabilitation programme in the

www.medicaljournals.se/jrm
 Effectiveness of rehabilitation programmes after TKA p. 3 of 12
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RCTs; each study at least had to include 3 out of 4 fitness com- Table I. Analysis of studies that used post-total knee arthroplasty
ponents (ROM, strength, walking or function) in the standard rehabilitation programmes
programme during the rehabilitation period. The experimental Number
group was defined as the group that used the additional method Combination of studies Studies
plus the above-mentioned fitness components. The studies were Early + Short 9 (Beaupe et al. 2001 (14); Bruun-Olsen et al.
categorized based on 2 factors commonly known to affect the 2009 (18); Denis et al. 2006 (15); Labraca et al.
2011 (19); Lenssen et al. 2006 (20); Lenssen
outcome of the rehabilitation programmes: the starting time- et al. 2008 (21); Mau-moeller et al. 2014 (22);
point and duration of the rehabilitation programme. Accordingly,
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Rahmaan et al. 2009 (16), Hardt et al. 2018

(23))
the studies were subdivided into 4 rehabilitation intervals: (i)
Early + Long 4 (Ebert et al. 2013 (24); Stevens- Lapsley et al.
early and short, (ii) early and long, (iii) late and short, and (iv) 2012 (25); Bade et al. 2017 (26); Demircioglu
late and long. The interval subdivision of the studies between et al. 2015 (27))
early and late rehabilitation was based on the wound-healing Late + Short 0
phases. After TKA the wound will be in the inflammatory Late + Long 5 (Jakobsen et al. 2014 (28); Lastayo et al. 2009
(29); Liao et al. 2013 (30); Piva et al. 2017
phase between 4 and 6 days (17), which is a natural response (37), Schache et al. 2019 (32))
to surgery. The signs elevate in the surrounding skin in exudate
levels, erythema, heat, oedema, pain and functional disturbance
(18). Some healthcare practitioners wait until the inflammation Characteristics of included studies
disappears before starting the rehabilitation programme, while
others prefer to start within that phase, arguing that rehabilita- All studies were randomized controlled trial (RCTs) with
tion exercises boost the anti-inflammatory response and, thus, a follow-up of between 6 weeks and 24 months, except
accelerate recovery. Therefore, in this review, the starting time- for one study with only a 4-day follow-up. The total
point factor was determined “early” when the rehabilitation
programme started within the first week, while programmes
number of patients was 1,417 (Table II). Studies reported
that started after that time-point were considered as that there are no differences between groups on baseline
“late” starting programmes. There were 13 studies
that started early (14–16, 18–27), while 5 studies Studies identified through electronic database Studies identified through electronic other
started late (28–32). As for the duration factor, there searching database searching

is a lack of uniform criteria to define the length of the Pubmed (n=2,633) PMC (n=2,868) Cochrane (n=211)
programme. In Germany the in-house rehabilitation
programme has a maximum duration of 3 weeks.
Accordingly, and for the sake of having a uniform
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Studies after duplicates removed

anchor point, programmes that ran for less than 3 Studies excluded
(n=2,301)
weeks were considered as “short” and programmes n=3,559

that ran more than 3 weeks as “long”. Nine studies

employed short programmes (14–16, 18–23), while
9 studies employed long programmes (28–32). Studies after screened by titles and
Studies excluded
When cross-checking the 2 factors, 8 studies start­ abstract (n=647)
ed early and had a short duration, 4 studies started n=1,258

early and had a long duration, no studies started late Studies excluded were using
Journal of Rehabilitation Medicine

and had a short duration, and 5 studies started late (n=344)

and had a long duration (Table I). Studies with full accessibility. Music (n=11)
n=611 Medication (n=87)

RESULTS Supporting devices (n=17)

Pre-operative (n= 229)

Studies after removing the non-practical
The initial search identified 267 potentially methods and/or contained pre-operative
relevant studies. After reviewing titles and rehabilitation.

abstracts and applying the inclusion and n=267

Studies excluded
exclusion criteria, only 18 articles (Bade (n=109)

et al. 2017 (26), Beaupre et al. 2001 (14),

Studies that apply unilateral or bilateral
Bruun-Olsen et al. 2009 (18), Demircioglu et prosthesis
Studies excluded
al. 2015 (27), Denis et al. 2006 (15), Ebert et n=158 (n=81)
kneecap replacement
al. 2013 (24), Hardt et al. 2018 (23), Jakobsen (patellofemoral arthroplasty)

et al. 2014 (28), Labraca et al. 2011 (19), Studies that compare standard with complex or revision knee
Lastayo et al. 2009 (29), Lenssen et al. 2006 proposed rehabilitation programs or
didn’t contain 3 out the 4 essential
replacement.

(20), Lenssen et al. 2008 (21), Liao et al. 2013 elements in the program.
Studies excluded
(30), Mau-Moeller et al. 2014 (22), Piva et al. n=77
(n=59)
2017 (37), Rahmann et al. 2009 (16), Schache
et al. 2019 (32), Steven-Lapsley et al. 2012 Studies that reported statistical Mean and Standard deviation
(25) fulfilled the inclusion and exclusion
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n=18
criteria for the systematic review and meta-
Fig. 1. Flow-chart of the literature search in Pubmed, PMC, and Cochrane. PMC:
analysis (Fig. 1 and Table II). PubMed Central.

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 p. 4 of 12 W. Alrawashdeh et al.
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Table II. Summary of the 18 randomized controlled trials included.

Study/country First day of Period Follow-up Groups Withdraw Description of Outcomes
intervention n = (women%) exercise/therapy

Bade et al. 2017 Day 4 11 w 12 M EXP1 EXP1 = 0 Both groups: Patients were seen Stair-climbing test, TUG,
USA (26) (HI) = 84 EXP2 = 0 3/w for the first 6/w and 2/w over 6MWT, ROM, MCS, SF-12,
the next 5 w. (26 sessions). (45 min muscle strength, WOMAC
n = 45, p = 54%
each session)
EXP2
Both had education on healing.
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(LI) = 87
Hi group: high-intensity,
n = 52, p = 66% progression-based, rehabilitation
programme-based. PRE targeting.
Weight-bearing, functional,
balance, agility, and activity
exercise (2 sets– 8 rep). 30 min
walking 5/w. swimming, cycling,
elliptical machine, stair climber. LI
group: time-based rehabilitation
programme. 1) iso and ROM ex for
the first 4/w. 2) slower transition
to w-b ex. 3) less progression in
difficulty of w-b ex 4) no resistance
beyond body weight or elastic bands
5) restricted activity outside of ADLs
for the first 4/w gradually building
to 30 min by the end of therapy
(restricted to walking and low-
resistance cycling)
Beaupre et al. 2001 Day 3 7d 6M EXP = 40 EXP = 9 EXP1: standard rehabilitation (ROM Walking, A/ROM Ex,
Canada (14) n = 20, p = 50% CON = 11 ex + strength ex + functional ex) isometric knee extension,
+ CPM stair-climbing.
CON = 40
CON: Standard rehabilitation + SB
n = 13, p = 30%
Bruun-Olsen et al. 2009 Day 1 after Op 6d 3M EXP = 30 n = 22, EXP = 5 EXP: CPM + active Ex: flexion/ ROM, pain, function,
Norway (18) p = 73% CON = 2 extension exercises, active isometric balance, walking
CON = 33 n = 22, contraction of the quadriceps,
p = 67% walking, climbing stairs (crutches),
passive movement.
CON: same programme without CPM
Demircioglu et al. 2015 Day 1 6w 3M EXP = 30 EXP = 0 Both groups started 30 min Knee extension, flexion,
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Turkey (27) n = 28, p = 93% CON = 0 (ROM)-(CPM)/w, ankle ROM ex, pain, stiffness, function,
isometric quadriceps ex, stand TUG, SF-36.
CON = 30
up with a walker and fully extend
n = 29, p = 96% their knees and active and assisted
ROM ex, Active ROM and isometric
quadriceps exercise, mobilization,
active hip abduction and adduction
ex. A home ex programme was
recommended. Closed kinetic chain
ex, 15 min cryotherapy. EXP: 1st/D
after surgery 30-min NMES on VM
5/D week, for 4–6 weeks*
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Denis et al. 2006 Day 2 after Op 7–8 d 2 years EXP = 28 EXP  =  1 EXP: CPM group 1 (35 min) + ROM (flexion-extension),
Canada (15) n = 14, p = 51.9% CON = 0 conventional TUG, WOMAC, length of
CON = 27 CON: Group 2 (2h): respiratory and stay
circulatory Ex, strength extension EX
n = 13,
and extension knee alignment, A/P
p = 46.4% knee flexion, abduction and add of
the hip in the horizontal plane, and
knee extensor muscle Ex, functional
Ex
Ebert et al. 2013 Day 2 after Op 6w 6w EXP = 24 n = 7, EXP = 0 EXP: Lymphatic drainage+ Active knee flexion and
Australia (24) p = 29% CON = 0 conventional therapy extension range of motion,
CON = 26 n = 7, CON: conventional therapy active- lower limb girths (ankle,
p = 27% assisted knee flexion + (active knee mid-patella, thigh, and
flexion + hip and knee flexion + calf), and pain
functional Ex + CPM + Cryotherapy
Hardt et al. 2018 Day 1 7d 7±1 d EXP = 22 EXP = 11 EXP: Genusport knee trainer extra. Active and passive range
Germany (23) n = 3, p = 12.5% CON = 2 CON: active and passive knee of motion (ROM), pain,
mobilization, gait training, assisted knee extension strength,
CON = 25
walking with crutches, strength TUG, 10-m Walk Test, 30-s
n = 4, p = 15.6% Chair Stand Test, (KOOS),
exercises, stair-climbing, manual
(KSS),
lymphatic drainage, and
cryotherapy 3 times daily with ice
packs.
Jakobsen et al. 2014 1 w after Op 6w 26 w EXP = 35 n = 21, EXP = 5 EXP: warming up + knee ROM Ex Walking, ROM (flexion,
Denmark (28) p = 60% CON = 2 + knee extensor stretches and extension), pain, 6MWT,
CON = 37 n = 16, 1-legged balance Ex + strength KOOS, Qof, activity of daily
p = 57% training + functional training + living, Oxford knee score.
balance training (the programme
was applied earlier)
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CON: Same programme

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 Effectiveness of rehabilitation programmes after TKA p. 5 of 12
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Table II. Cont.

First day of Groups Description of

Study/country intervention Period Follow-up n = (women%) Withdraw exercise/therapy Outcomes

Labraca et al. 2011 Within the first 4d 4d EXP = 153 n = 101, EXP = 15 EXP: P/A ROM + Strength Ex- ROM, muscle strength,
Spain (19) 24 p = 73.1% CON = 18 flexion/extension + breathing + pain, autonomy, gait, and
CON = 153 n = 110, Functional EX (the programme was balance
p = 81.4% applied earlier)
CON: same programme
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Lastayo et al. 2009 1 – 4 years 12 w 3M EXP = 9 n = 7, EXP = 0 EXP: Strength Ex + ROM+ NMES+ Quadriceps volume,
USA (29) after Op p = 77.7% CON = 0 Walk+ setups + wall squat extension strength, TUG,
CON = 8 n = 6 (Eccentric (ECC) resistance Ex- 6MWT, stairs (ascending,
p = 75% machine/additional) descending)
CON: same programme without ECC
training
Lenssen et al. 2006 Day 1 4d 3M EXP = 21 n = 15, EXP = 0 EXP: A/P mobilization of the Passive flexion ROM,
Netherlands (20) p = 71.4% CON = 0 knee joint + active strengthening active ROM and passive
CON = 22 n = 17, (quadriceps) + ADL functions extension ROM, functional
p = 77.2% treatment session (30 min), mean status, length of stay, pain,
total of treatment sessions EXP- satisfaction with treatment
CPM more than the CON group
CON: same programme
Lenssen et al. 2008 Day 1 after Op 17 d 3M EXP = 30 n = 18, EXP = 0 EXP: active and passive mobilization Functional status,
Netherlands (21) p = 60% CON = 0 of the knee + strengthening of the ROM, perceived effect,
CON = 30 n = 21, quadriceps muscle + functional postoperative medication,
p = 70% exercises + transfers from a supine satisfaction with
position to sitting and from sitting treatment, quantity,
to standing + walking and stair duration, and nature of PT
climbing intervention
CON: same programme
Liao et al. 2013 At least 2 8w 8w EXP = 58 n = 46, EXP = EXP: Exercises for strength + Walking, balance,
Taiwan (30) months after p = 79.3% CON = walking + endurance + 30 min functional walking, pain,
Op CON = 55 n = 37, function + 60 min balance stiffness, function
p = 67.2% CON: same programme without
balance EX
Mau-Moeller et al. 2014 Day 1 after Op 3w 3M EXP1 EXP1 = 7 EXP1: Standard care + sling training ROM, pain, physical
Germany (22) (Sling) = 19 n = 7, EXP2 = 10 (ST) activity, static posture
p = 36.8% EXP2: Standard care = A/P ROM Ex control, function, QoL
+ Strength (quadriceps) + ADL Ex
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EXP2
+ walking + climbing stairs. Ex for
CPM = 19 n = 9,
pain and tolerance
p = 47.3%
Piva et al. 2017 After discharge 3 d 6M EXP = 22 n = 18, EXP = 0 EXP: Warm up-5 min. Endurance- Pain, function, stair-
USA (31) p = 82% CON = 0 20 min treadmill walking 50–75% climbing, chair-standing,
CON = 22 n = 13, intensity. Resistance ex (knee single-leg stance, 6MWT,
p = 59% extensor, flex, hip extension, gait speed, daily activity
abduction) 60–80%. ((2 steps – 8
rep). Skilled ex 15 min. Education
sessions.
CON: Warm up – 15 min (bike).
Endurance – 20 min (treadmill
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walking). Resistance ex – 40–50%.

Both had home Ex
Rahmann et al. 2009 Day 4 14 d 12 M EXP = 18 n = 8 EXP = 10 EXP: Water programme: Hip Hip abductor strength,
Australia (16) p = 44.4% CON = 3 adduction/abduction, squats, heel walking speed, self-
CON = 17 n = 12, raises walk, lunges, stability Ex, hip reported disability
p = 70.5% extension, knee: walking, lunges, (WOMAC), ROM,
ROM quadriceps + hamstring
CON: same programme without strength, function
aquatic Ex
Schache et al. 2019 2 w after Op 6w 26 w EXP = 54 EXP = 6 EXP: Extra exercises targeting the Pain, knee extension-
Australia (32) n = 39, p = 72% CON = 3 strengthening of the hip abductor flexion, hip strength,
muscles quadriceps strength, chair-
CON = 51
CON: All participants received stand test, stair-climbing
n = 30, p = 58%
exercises to improve quadriceps, test, 40 m fast-paced walk,
hamstring, and calf strength, TUG, step taps, 6MWT.
increasing knee range of movement
and improving walking and stair-
climbing ability. These exercises
have been described in detail
previously.17 Manual therapy,
including joint mobilization and
massage,
Steven-Lapsley et al. Day 2 after Op 6w 52 w EXP = 35 n = 20, EXP = 5 EXP: Exercises + NMES+ P/A ROM Iso-quadriceps and
2012 p = 57.1% CON = 6 Ex + Functional Ex + ROM Ex + hamstring torque and
USA (25) CON = 31 n = 16, strengthening W/B non-W/B + activation testing, NMES
p = 51.6% walking dose assessment, function,
CON: Passive (ROM) + cycling + pain, ROM, health status
flexibility + walking + functional questionnaires.
training + strength
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D-day, W-week, M-month, EXP-experimental, CON-control, ROM-range of motion, A/P ROM-active/passive range of motion, TUG-time up and go test, 6MWT-6
minutes walking test, MCS-Mental Component Score, SF-12-Short Form Survey, ADL-activity of daily living, CPM-Continuous Passive Motion, SB-Slide Board,
EX-exercise, NMES-Neuromuscular Electrical Stimulation, VM-Vastus medialis, KOOS-Knee Injury and Osteoarthritis Outcome Score, KSS-Knee Society Score,
Qof-Quality of life, ECC-Eccentric, PT-Physiotherapy, OP-Operation, ST-Sling training, non-W/B non-weight bearing.

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 p. 6 of 12 W. Alrawashdeh et al.

(31), continuous passive motion (CPM) (15, 18, 21),

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Table III. Summary of the patient rehabilitation situation

(inpatient–outpatient)
sliding board (14), early high-intensity vs low intensity
Studies with both
Studies with inpatient Studies with outpatient inpatient and (26), strength exercise (23, 28, 29, 32), sling exercise (22),
rehabilitation (n =  9) rehabilitation (n =  7) outpatient (n =  1) and fast track (19, 20). Six studies (21, 25, 26, 28, 29, 31)
Beaupre et al. 2001 (14) Bade et al. 2017 (26) Steven-Lapsley et al. provided home exercises during the rehabilitation period.
Bruun-Oslen et al. 2009 (18) Demircioglu et al. 2015 (27) 2011 (25)
The studies were subdivided into inpatient and out-
Denis et al. 2006 (15) Jakobsen et al. 2014 (28)
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Ebert et al. 2013 (24) Lastayo et al. 2009 (29)

patient groups (Table III)
Hardt et al. 2018 (23) Liao et al. 2013 (30)
Labraca et al. 2011 (19) Piva et al. 2017 (37) Quality assessment
Lessen et al. 2006 (20) Schache et al. 2019 (32)
Lessen et al. 2008 (21) In terms of quality, the mean PEDro score of the studies
Moeller et al. 2014 (22)
Rahmann et al. 2008 (16)
was 8.7 (Table IV). All studies reported eligibility
criteria except for 3 studies (14, 18, 20). Two studies
did not explain their randomization strategy clearly
measurement. Overall mean age was approximately 67.1 (20, 29). Blinding assessors occurred in 9 of 18 studies,
years (SD 2.5) and the percentage of females was 64.2%. respectively (19–21, 24, 26, 29–32).
Interventions varied widely across studies. The specific
rehabilitation programmes, which were compared with
Knee range of motion
standard programmes, included water exercise (16),
balance exercise (30), manual lymphatic drainage (24), Knee ROM was measured with a standard goniometer,
neuromuscular electrical stimulation (NMES) (25, 27), and covered active flexion and extension of the knee
comprehensive behavioural and exercise intervention from different positions, e.g. during seated, supine, lying

Table IV. PEDro scale included studies (n = 18)

Pedro Clinical Appraisal Score

Patients Groups Measures All subjects There was some The

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Inclusion, were presented obtained from received comparative analysis

exclusion casual similar Blind Blind Blind more than 85% treatment analysis between was
Study criteria Randomization extract income data patients therapists assessor of initial subjects or control the groups satisfaction Total/11

Bade et al.            10
2017 (26)
Beaupre et al.            9
2001 (14)
Bruun-Olsen            9
et al. 2009
(18)
Demircioglu            8
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et al 2015
(27)
Denis et al.            9
2006 (15)
Ebert et al.            9
2013 (24)
Hardt et al.            8
2018 (23)
Jakobsen et            8
al. 2014 (28)
Labraca et al.            9
2011 (19)
Lastayo et al.            9
2009 (29)
Lenssen et al.            9
2006 (20)
Lenssen et al.            9
2008 (21)
Liao et al.            10
2013 (30)
Moeller et al.            8
2014 (22)
Piva et al.            9
2017 (37)
Rahmann            7
et al. 2008
(16)
Schache            9
et al. 2019
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(32)
Steven-            7
Lapsley et al.
2012 (25)

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 Effectiveness of rehabilitation programmes after TKA p. 7 of 12

and prone positions. The results compared improvement for these negative results (15, 18, 21). Heterogeneity
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and lack of it between experimental and control groups was high, at 90%.
after the rehabilitation programme ended. The active The active flexion ROM dataset was available for 13
extension ROM dataset was available for 12 studies (991 studies (n = 1.025 patients) (14–16, 18–22, 24–27, 32).
patients) (14, 15, 18–22, 24–27, 32), the mean and SD The mean and SD for the following-up period was 218.8
of the following-up period was 204.2 days (SD 220.1). days (SD 220.1), where the comparison for knee flexion
Journal of Rehabilitation Medicine

The comparison for knee extension was numerically in was numerically in favour of the control group (EE 3.33;
favour of the experimental group (EE –0.24; 95% CI 95% CI –0.18 to 6.83; p = 0.06, Fig. 3). In active flexion
–1.29 to 0.81; p = 0.65, Fig. 2). In the active extension ROM, no significant differences were found in the 13
ROM, no significant differences were found in the 11 studies between modified and standard rehabilitation
studies between the modified and the standard rehabilita- programmes after TKA. Eleven studies shared a starting
tion programmes after TKA. The studies shared the same time, which was within the first 4 days after surgery. Two
starting point for the rehabilitation programme, which studies started directly after discharge. Four studies found
was within the first 36 h after surgery, the differences better mean improvement for the experimental group (18,
were in the duration and the method used, except for 20–22). Two out of these 4 studies used CPM plus strength,
one study Schache et al. (32), which started 2 weeks function and walking exercises (21, 22). The third study
after the operation. One study had an equal mean result used functional exercises (20), and the fourth used sling
between the 2 groups, so no preference was analysed for exercises (22). The other 9 studies showed better mean
the methods used in either the experimental or control improvement for the control group. Seven studies used
groups (14). Five studies out of the 12 reported improve- different methods (e.g. sliding board technique, active/
ments in the ROM mean in the experimental group (19, passive exercises and water exercises for ROM, NMES,
20, 24–26). The other studies reported improvement extra strength exercise for hip), which were added to the
in the ROM mean in the control group (15, 18, 21, 22, individual programmes (14, 16, 19, 24, 25, 27, 32). The
27, 32). Three out of these 6 studies used CPM as the eighth study used early high-intensity progression (26).
main method to regain the ROM, without considering The ninth study used CPM parallel to strength and function
the other methods or exercises, which could be a reason exercises (15). Heterogeneity was also high, at 91%.
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Journal of Rehabilitation Medicine

Fig. 2. Forest plot of the knee extension comparison. SD: standard deviation; 95% CI: 95% confidence interval.
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Fig. 3. Forest plot of the knee flexion comparison. SD: standard deviation; 95% CI: 95% confidence interval.

J Rehabil Med 53, 2021

 p. 8 of 12 W. Alrawashdeh et al.

Pain Western Ontario and McMaster Universities

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Pain was measured in 544 patients in 6 studies using Osteoarthritis Index

a visual analogue scale (VAS). The results were taken The overall results of the WOMAC were chosen in­stead
after the rehabilitation programme ended. The mean of 1 or 2 attributes. Eight studies with 569 patients used
and SD for the follow-up period was 91.6 days (SD WOMAC to analyse pain, stiffness, and function. The
56.3). The comparison of VAS was numerically in mean and SD for the following-up period was 269.1
Journal of Rehabilitation Medicine

favour of the experimental group (EE –0.71; 95% CI days (SD 233.1). The comparison of WOMAC resulted
–1.85 to 0.43; p = 0.22, Fig. 4). No significant differ­ in a significant improvement in the experimental group
ences were found in the 6 studies between modified (EE –2.43; 95% CI –4.71 to –0.14; p = 0.04, Fig. 5).
and standard rehabilitation programmes after TKA. Eight studies used a WOMAC questionnaire to collect
The 6 studies used visual analogue scale (VAS) and information about pain, stiffness, and function in their
calculated the mean and SD (18–20, 22, 27, 28). There patients (15, 16, 21, 22, 25–27, 30). Seven studies had
was no significant difference in the combined result. an early starting point for rehabilitation, within 48 h,
All studies had an early starting rehabilitation point, except one study, which started at least 2 months after
within 48 h, except one study that started one week surgery (30). The combined result was significant for
after surgery (28). Four studies out of 6 had better the experimental groups. All of the studies shared the
mean improvement in the experimental group than same programme components (strength, ROM, walking
in the control group (19, 22, 27, 28). One of these and function exercises). One study had significant
4 studies used progressive strength, in parallel with improvement in the overall WOMAC at the end of the
ROM exercises, strength, function and walking (28). rehabilitation programme (30). Liao et al. (30) added
The second study used sling exercise training (22). balance and endurance exercises, which might explain
The third study used the same combination earlier this positive result for WOMAC in this study. Hetero-
than the control group, adding extra exercises, such geneity was moderate, at 48%.
as transfer and active daily living exercises (19). The
fourth study used neuromuscular electrical stimulation
(NMES) in parallel with strength, ROM, function, and 6-minute walking test
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walking exercises (27). The remaining 2 studies had The 6MWT measures the maximal distance a subject
better improvement in the control groups (18, 20). is able to walk in 6 min, and is a moderately valid in-
Heterogeneity was high, at 88%. dicator of submaximal and maximal aerobic capacity
Journal of Rehabilitation Medicine

Fig. 4. Forest plot of the visual analogue scale (VAS) comparison. SD: standard deviation; 95% CI: 95% confidence interval.
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Fig. 5. Forest plot of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) comparison. SD: standard deviation; 95% CI:
95% confidence interval.

www.medicaljournals.se/jrm
 Effectiveness of rehabilitation programmes after TKA p. 9 of 12

(r = 0.53) in patients with knee OA (33). Six studies tion programmes, except for one study (25). Only one
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with 437 patients used 6MWT (25, 26, 28, 29, 31, study showed a lack of difference between groups (16).
32) . The mean and SD for the following-up period Five studies had non-significant improvements in the
was 227.8 days (SD 111.9). All the studies had long experimental group (23, 25–27, 29). One study had an
rehabilitation programmes. The difference was in the equal mean result (32). One study showed significant
starting point, where 4 studies started late and lasted improvement in the experimental group (30). Hetero-
long (28, 29, 31, 32) and the other 2 started early (25, geneity was moderate, at 52%.
Journal of Rehabilitation Medicine

26). The comparison of 6MWT was numerically in

favour of the control group (EE 4.34; 95% CI –20.74 to
DISCUSSION
29.41; p = 0.17, Fig. 6). The combined result showed no
significant difference between groups. Heterogeneity The main finding of this study is that there is no specific
was moderate, at 35%. rehabilitation method that can be recommended after
TKA regardless of the time it will be applied after the
operation.
Timed Up and Go test
Many meta-analyses have compared rehabilita-
The TUG test measures the time to rise from an arm- tion methods or compared the effect of rehabilitation
chair, walk 3 m, turn around, and return to sitting in programmes on the length of stay. Artz et al. (33)
the same chair without physical assistance (34). Eight conducted a systematic review that found no differenc­
studies with 584 patients included TUG (16, 23, 25–27, es in physical function and pain outcomes between
29, 30, 32). The mean and SD for the following-up physiotherapy with no supervision and home exercise
period by days was 239.3 (SD 108.6). Comparison of with outpatient supervision in the short-term. The only
the TUG test resulted in a significant improvement in difference in one study was that walking skills inter-
the experimental group (EE –0.65; 95% CI –1.14 to vention was associated with long-term improvement
–0.17; p = 0.009; Fig. 7). Eight studies used TUG in in walking performance. A review by Sattler et al. (35)
their measurements (16, 23, 25–27, 29, 30, 32). The compared 4 different early supervised exercise therapy
combined result was significant for the experimental programmes, commencing within 48 h after TKA. The
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groups. All studies had almost the same programme study reported that there are no significant differences
components, consisting of strength, ROM and walking between groups in the maximum knee flexion or knee
exercises. The difference was in the starting point; 3 society score after 6 weeks post-operation.
studies started late (29, 30, 32) and the other 5 started Regarding the movement in the knee joint, knee
early (16, 23, 25–27). All studies had long rehabilita- ROM is the main follow-up outcome after TKA, and it
Journal of Rehabilitation Medicine

Fig. 6. Forest plot of the 6-minute walking test (6MWT) comparison. SD: standard deviation; 95% CI: 95% confidence interval.
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Fig. 7. Forest plot of the Timed Up and Go (TUG) comparison. SD: standard deviation; 95% CI: 95% confidence interval.

J Rehabil Med 53, 2021

 p. 10 of 12 W. Alrawashdeh et al.

is believed to reflect patient progression, although it is to improve WOMAC according to the time interval.
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a poor marker of implant success (13). For active knee The 6MWT is one of the common tests used in
extension and flexion ROM, comparison between stan- studies, especially for interventions in the lower limbs
dard and modified rehabilitation programmes was con- (40). We found 6 studies that used 6MWT (25, 26, 28,
ducted. Active knee extension and flexion ROM were 29, 31, 32). The studies shared the same programme
based on 12 studies with 991 patients, and 13 studies components (strength, ROM, walking, and function
with 1,025 patients respectively. However, no signifi- exercises). Four out of 6 studies were late-long, and
Journal of Rehabilitation Medicine

cant differences were found between the standard and the other 2 were early-long. The result did not indicate
modified rehabilitation programmes after TKA. In ad- that the starting point or the duration affect the 6MWT.
dition, high heterogeneity was observed in the current This finding was supported by 2 studies, which applied
meta-analyses of ROM, possible causes being the use different rehabilitation programmes with different
of different measurement positions across studies and starting points (41).
difficulties extracting data from studies, particularly in Finally, the TUG test is a timed test, in which par-
the case of active extension, where negative values can ticipants start in a seated position in an armchair and
be misleading and the low reliability of the instruments then rise, go forward 3 m, turn around, and sit back
employed (36). Furthermore, considering knee flexion, down (29). Eight studies were found that used TUG in
the programmes perhaps, missing the walking part of their trials (16, 23, 25–27, 29, 30, 32). The combined
the programme gave this negative result, in contrast to result was significant for the experimental group. As
other studies using continuous passive motion (CPM). mention­ed above, the studies had almost the same pro-
From these outcomes regarding both factors, knee gramme components. The difference was at the starting
extension and flexion, it seems that depending on point. Referring to this result, we believe that the com-
CPM alone does not improve knee extension, but does bined result is skewed, and, thus the current outcome
improve knee flexion after TKA. must be considered with caution. Another interesting
Pain is one of the most important outcomes after finding is that the starting point of the rehabilitation
TKA. The persistence of pain after surgical procedures programmes does not seem to have any effect on the
has become a major focus of interest, and its prevention result, while the long period of rehabilitation suggests
JRM

now represents a challenge for caregivers as an index a clinical added value.

for the quality of healthcare (36). Pain was reported
in 6 studies (18–20, 22, 27, 28). These studies used a Study limitations
combination of ROM, strength, function, and walking. This meta-analysis has some limitations. There was a
Pain reduction post-TKA was reported in 4 different high level of heterogeneity between studies, and hence
studies, each implementing a different additional the data had to be interpreted with caution.With regard
method (19, 20, 27, 28). This suggests that no parti- to the use of subgroup analysis to reduce heterogeneity,
Journal of Rehabilitation Medicine

cular method has a unique advantage in reducing pain. this was precluded by a lack of data
This result corresponds with the result of a study by
Chughtai et al. (37), that there were no clear guide­lines to
Conclusion
reduce pain while using different non-pharmacological
therapy, such as NMES, transcutaneous electrical nerve When comparing modified rehabilitation programmes
stimulation (TENS) or cryotherapy. with standard programmes post-TKA, there is no clear
Regarding WOMAC, the current study showed sig- pattern in the combination of starting time-point and
nificant differences in the combined result. Six studies duration of rehabilitation that significantly improves
out of 8 reported improvements in the experimental clinical outcomes. Moreover, improved clinical out-
group, 2 studies were early-short (15, 21), 3 were early- comes could not be attributed solely to any particular
long (23, 25, 26) and one study was late-long (30). The modification to the programmes. Accordingly, a one-
2 studies that reported improvement for the control size-fits-all approach to modified rehabilitation pro-
group were early-short (16, 22). During the search, grammes does not result in systematic improvement
studies were identified that supported our findings in clinical outcome.
and others contradicted it. A study by Hertog et al. (3)
supported the early-long rehabilitation interval. On the
other hand, in the same interval, a study by Mahomed ACKNOWLEDGEMENT
et al. (38) demonstrated contradictory results from the This work was supported by the German Academic Exchange
study of Hertog et al. (3). Furthermore, a study by Piva Service (DAAD), Research Grant- Doctoral programmes in
JRM

et al. (39) found contradictory results from the late- Germany, under grant 57129429.
long result. It seems that there is no specific method The authors have no conflicts of interest to declare.

www.medicaljournals.se/jrm
 Effectiveness of rehabilitation programmes after TKA p. 11 of 12

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