Melvin G. Joice, BSE; Subhrojyoti Bhowmick, MD; Derek F. Amanatullah, MD, PhD
Orthopedics
Posted May 22, 2017
DOI: 10.3928/01477447-20170518-03
Abstract
Total knee arthroplasty has a high success rate. In the interest of enhancing patient outcomes, numerous perioperative interventions have been studied, including preoperative education, preoperative rehabilitation, postoperative inpatient rehabilitation, continuous passive motion, postoperative outpatient rehabilitation, unsupervised in-home exercises, telerehabilitation, and various combinations of these. This comprehensive review analyzes the existing body of evidence on these perioperative interventions and examines some burgeoning opportunities in rehabilitation after total knee arthroplasty in the interest of improving patient outcomes and ensuring sustainable health care utilization for the future of total knee arthroplasty. [Orthopedics. 201x; xx(x):xx–xx.]
Total knee arthroplasty (TKA) is the gold standard of treatment for patients with end-stage arthritis of the knee. As of 2010, more than 620,000 TKA procedures were performed annually in the United States.1 By 2030, this is predicted to reach 3.5 million annually.2 Even with these high volumes, the 2003 National Institutes of Health consensus statement on TKA concluded that “the use of rehabilitation services is perhaps the most under-studied aspect of the perioperative management of TKA patients . . . [and] there is no evidence supporting the generalized use of any specific pre-operative or post-operative rehabilitation intervention.”3 In response to this statement, investigators have reported on a plethora of rehabilitative techniques and regimens available for perioperative management of TKA patients. In the United States, rehabilitation after TKA refers to several different practice settings depending on the patient, the health care system, and treatment decisions made by both the health care team and the patient. “Rehabilitation” begins at or before entering the acute inpatient setting, where decisions are made concerning the most appropriate discharge location for the patient. Possible discharge locations for a patient after TKA are a skilled nursing facility, an inpatient rehabilitation facility, home with home health physical therapy, home with a prescribed home exercise program, or outpatient physical therapy.4 Müller et al5 observed that best practice in rehabilitation is largely based on clinical experience, local customs, anecdotal evidence, surgeon preferences, clinical pathways established for the acute-care phase of recovery, and health insurance funding schemes.
This review reports the numerous available rehabilitation options, highlights the regimens with the highest level of evidence-based consensus, and examines some burgeoning opportunities in rehabilitation that may be necessary to keep pace with the increasing demand for TKA.
Materials and Methods
Search and Selection
In May 2016, a thorough search was conducted of MEDLINE (from 1966), the Cochrane Library, and the Physiotherapy Evidence Database (PEDro). Included were studies published in English, concerning perioperative interventions for primary TKA, with well-established outcome measures, considered randomized controlled trials (RCTs), with a matched cohort, considered comparative retrospective case series, and considered applicable Cochrane reviews and meta-analyses. Excluded studies included those with data not reported, those with nonquantitative outcome measures, or those published prior to 1985. Search terms included total knee arthroplasty, physiotherapy, rehabilitation, management, preoperative, postoperative, continuous passive motion, telerehabilitation, in-home exercises, neuromuscular electric stimulation, diet, and Wii as isolated terms and in combination.
Data Analysis
For specific interventions that had sufficient data, a forest plot was constructed to analyze effectiveness. Only continuous passive motion (CPM) as an intervention had enough data in the existing literature to be analyzed. Any study since 1990 that had adequate reporting of data to analyze was included. Of the 28 studies found concerning CPM, 17 were included.6–22 Eleven studies were not included, mainly due to incomplete data reporting.23–34 Of the excluded studies, some did not report standard deviations, others did not use a standard protocol for the measurement of range of motion (ROM), and one was out-side the date range specified in the inclusion criteria.
To generate the forest plots, the standardized mean differences between treatment groups on each outcome were calculated at each time point for which data were available, as well as 95% confidence intervals for these effects. These effect size estimates were then pooled across the subset of studies making the same treatment comparisons at the same time points using standard random effects meta-analytic methods. All analyses and plotting were accomplished using the rmeta, meta, and es.compute libraries of the R statistical program (version 3.0.0; R Foundation) released in 2014.
Discussion
Preoperative Interventions
Preoperative Patient Education. Pre-operative education refers to any educational intervention delivered before surgery that aims to improve the patients’ knowledge, perspectives, health behaviors, and/or health outcomes.35–37 Although the content of preoperative education varies, it often includes discussion of administrative procedures, the surgical procedure, postoperative care, potential stressful scenarios, potential complications, pain management, and movements to perform or avoid after surgery.38
Chen et al39 randomized patients (n=92) to receive either a pamphlet or educational videos and a skill-teaching session for rehabilitation or usual standard care. Patients receiving the additional materials reported lower pain scores up to 2 days postoperatively; after that, the only significant differences were in stair climbing time, eating, and the regularity of performing straight-leg raises. Crowe and Henderson40 provided patients (n=133) with a 50-minute video, an informational booklet, a tour of the postoperative hospital unit, and a demonstration of how to use the postoperative equipment. Although they found that length of stay (LOS) could be reduced by offering comprehensive individualized educational materials for patients, they did not find significant differences in joint flexion, the 30-minute walking test, or stair climbing.40 Encompassing 12 similar studies (n=1567), a systematic review conducted in 2015 analyzed the effect of preoperative education on anxiety, pain, LOS, patient satisfaction, postoperative complications, mobility, and expectations. Among these outcomes, preoperative education was only found to be effective in reducing preoperative patient anxiety.41
Current evidence seems to indicate that a focus on preoperative education has little clinical benefit. Although preoperative education should remain a part of the clinical pathway in TKA, no extra resources or time apart from the standard of care seems to be indicated currently.
Physiotherapy/Prehabilitation. Preoperative physiotherapy or “prehabilitation,” whether in a home setting or a clinical setting, is theorized to improve postoperative TKA outcomes by increasing knee ROM and strengthening the quadriceps muscles before surgery. A graphical representation of this theory, similar to one presented by Ditmyer et al,42 is shown in Figure 1.
Proposed prehabilitation model. It is postulated that rehabilitation before surgery results in better postoperative outcomes. Abbreviation: TKA, total knee arthroplasty.
Figure 1:
Proposed prehabilitation model. It is postulated that rehabilitation before surgery results in better postoperative outcomes. Abbreviation: TKA, total knee arthroplasty.
In 2007, Williamson et al43 (n=181) administered a 6-week course of preoperative physiotherapy that included “static quadriceps contractions, inner range quadriceps contractions, straight leg raises, sit-to-stands, stair climbing, calf stretches, theraband resisted knee extensions, wobble board balance training, knee flexion/extension sitting on gym ball, and free-standing peddle revolutions.” They found no significant differences in LOS, Oxford knee score, 50-minute walking test, visual analog scale score, or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Mitchell et al44 conducted an RCT (n=160) comparing patients who received preoperative and postoperative physiotherapy with those who received only postoperative physiotherapy. Preoperative physiotherapy included pain relief, techniques to increase knee flexion and extension, gait reeducation, and functional adaptations.44 For all outcome measures, including WOMAC, stiffness, and Short Form-36 scores, the authors found no significant differences for patients receiving the extra preoperative physiotherapy.
Contrastingly, some studies have found significant short-term differences in post-operative outcomes when administering preoperative physiotherapy to TKA patients. In 2014, Matassi et al45 randomized patients (n=122) to either receive a preoperative 6-week home-based exercise program or continue normal activities until surgery. With a 79% compliance rate with the at-home regimen, the authors concluded that preoperative home-based exercise offered a boon in short-term knee ROM, but had no significant effect on knee ROM or Knee Society score 1 year after TKA.45
Despite the body of evidence mounting against both preoperative education and preoperative physiotherapy individually, it was hypothesized that combining these interventions might offer superior post-operative outcomes in TKA. Beaupre et al46 randomized patients (n=131) to either a combined education/exercise program that consisted of 3 sessions for 4 weeks preoperatively or a control group that received usual care. They found no significant differences in ROM, pain, function, or health-related quality of life up to 1 year after TKA.46
Overall, recent reviews and meta-analyses unanimously agree that patient outcomes are not significantly affected in the long-term by preoperative physiotherapy regimens.47–49 Wallis and Taylor49 hypothesized that preoperative physiotherapy shows little effect because “it is possible that marked reduction of pain that comes from replacing painful joint surfaces during surgery far outweighs modest contribution from pre-operative interventions.” An alternative hypothesis is that patients are so significantly deconditioned from the surgery that any benefits gained from preoperative rehabilitation are muted.50 The revised model for the effects of preoperative physiotherapy is shown in Figure 2. Currently, preoperative rehabilitation is rarely prescribed by surgeons because of the lack of long-term postoperative benefits.51
Figure 2:
Actual prehabilitation model. By current evidence, rehabilitation before surgery does not affect postoperative outcomes. Abbreviation: TKA, total knee arthroplasty.
Short-term Postoperative Interventions
Inpatient Rehabilitation. Inpatient rehabilitation refers to any intervention that follows immediately after TKA and prior to initial discharge. Although there is large consensus on the importance of a rehabilitation regimen immediately following TKA, little agreement exists on the exercises that comprise the regimen, the intensity of exercises, and the duration. Recent regimens reported in the literature vary in duration from 3 to 14 days and have employed interventions such as walking, stretching, gait retraining, CPM, aquatic therapy, quadriceps strengthening exercises, and stair climbing exercises. Contemporary inpatient regimens have shorter durations and more intense exercises and begin on the day of surgery or the first postoperative day.
Aggressive rehabilitation is believed to be important in preventing postoperative contracture of the soft tissue and in gaining better flexion postoperatively. Pua and Ong52 (n=1504) studied the significance of ambulation on the first postoperative day and found that it resulted in a significantly shorter LOS, lower hospitalization costs, and improved knee function. Zietek et al53 (n=66) increased the intensity of rehabilitation on the first postoperative day by adding an extra 15-minute walk with a walker 3 hours after an initial 15-minute walk. They found no detriment to the added intensity and suggested a further increase in intensity. However, when Lenssen et al54 (n=43) increased inpatient rehabilitation intensity to 2 physical therapy sessions a day in an RCT, they found no significant gain in ROM.
Isaac et al55 randomized patients (n=50) to investigate an accelerated rehabilitation protocol that included infiltration of bupivacaine and adrenaline into the divided tissue layers at the time of surgery, spinal anesthesia, mobilization on the day of surgery, an organized multidisciplinary approach anticipating issues that may delay discharge, and an expectation of an earlier discharge from the hospital. They showed a 6.9-day decrease in LOS, with comparable pain levels, Knee Society score, and Oxford knee score. Similarly, in a randomized clinical trial (n=185), a rapid recovery protocol after TKA was tested in a low-resource military hospital setting; the protocol included preoperative patient education, ambulation on the first postoperative day, and pain management with celecoxib and oxycodone.56 The protocol decreased LOS by 2.9 days and saved an average of $1511 in hospitalization costs without causing any adverse health outcomes.
Overall, inpatient rehabilitation in the immediate postoperative setting is the most important intervention in perioperative management of TKA. In recent years, the regimens have become shorter and more aggressive, including postoperative ambulation on the day of surgery or the first day following surgery. There is evidence to indicate that shorter courses of rehabilitation do not adversely affect patients and are beneficial in terms of LOS and hospitalization costs.
Continuous Passive Motion. The mechanism of CPM has been hypothesized to be twofold: facilitating the movement of synovial fluid to allow for better diffusion of nutrients into damaged cartilage with diffusion of other materials out, and preventing fibrous scar tissue formation in the joint, which tends to decrease ROM.
Studies on the use of CPM have had conflicting results. Early studies indicated that CPM had a short-term benefit after TKA by increasing knee ROM and improving wound healing.27 Other studies purported that CPM may be optimized if initiated immediately after TKA.11,15,23,31,57 However, more recent studies seem to refute these findings, claiming no benefit in CPM after TKA.6–8,18–20,28,29,32–34,58 In an attempt to make sense of the conflicting evidence, several systematic reviews have been conducted. However, these reviews have had conflicting conclusions as well. Older reviews seem to favor the use of CPM,59.60 while more recent reviews seem to show no benefit.61,62
Conflicting conclusions of the systematic reviews were a result of different inclusion and exclusion criteria. Reviews that included studies in which post-TKA patients who received CPM were compared with patients whose knees were immobilized found a benefit with CPM. Contrastingly, reviews that only included studies in which patients who received CPM were compared with patients who received conventional physiotherapy found no benefit with CPM. This difference in comparison explains why earlier reviews found CPM to be beneficial—they were conducted at a time when the standard of care for acute postoperative TKA was knee immobilization. More recent reviews compared CPM with the current standard of care, physiotherapy, and found no difference. Thus, critical scrutiny of the literature against the backdrop of normal clinical practice provides a unified conclusion supporting postoperative rehabilitation in TKA, in the form of conventional physiotherapy or CPM, because knee motion is more beneficial than knee immobilization. Further, this unified conclusion supports the idea that CPM offers little to no additional benefit to conventional postoperative physiotherapy.
To validate the unifying theory concerning discordant conclusions in CPM studies and meta-analyses, forest plots were generated that stratified the control group to either postoperative immobilization or physical therapy. In the CPM vs immobilization data analysis, ROM was analyzed at time points of 3 and 12 months (Figure 3). The pooled data showed no significant ROM improvement at either time point. In the CPM vs physical therapy data analysis, the time points included discharge, 3 months, 6 months, and 12 months (Figure 4). Regardless of time point, none of the changes in ROM represented a clinically significant difference with the use of CPM when compared with the use of physical therapy.
Continuous passive motion (CPM) vs immobilization (IM) at 3 months and 12 months. With just a few studies, conclusions are difficult to draw. However, a few studies found CPM, compared with IM, to be helpful in increasing range of motion. Abbreviation: CI, confidence interval.
Figure 3:
Continuous passive motion (CPM) vs immobilization (IM) at 3 months and 12 months. With just a few studies, conclusions are difficult to draw. However, a few studies found CPM, compared with IM, to be helpful in increasing range of motion. Abbreviation: CI, confidence interval.
Continuous passive motion (CPM) vs physical therapy (PT) at discharge, 3 months, 6 months, and 12 months. At all time points, CPM was not found to be helpful in increasing range of motion. Abbreviation: CI, confidence interval.
Figure 4:
Continuous passive motion (CPM) vs physical therapy (PT) at discharge, 3 months, 6 months, and 12 months. At all time points, CPM was not found to be helpful in increasing range of motion. Abbreviation: CI, confidence interval.
Comparing the 2 stratified analyses, the largest absolute mean difference was seen in CPM vs immobilization at 12 months. This offers some insight into why CPM was thought to be beneficial when compared with immobilization but not when compared with physical therapy. Overall, the authors’ analysis of current literature suggests that there is little benefit to any patient receiving CPM after primary TKA in the backdrop of the current standard of care that includes postoperative physical therapy, indicating that CPM is an unnecessary overuse of medical resources.
Long-term Postoperative Interventions
Outpatient Physical Therapy. Physical therapy that begins after hospital discharge has long been considered the standard of care in the rehabilitation after TKA, reliably facilitating ROM, strength, and quality of life improvements. Outpatient rehabilitation can range from 3 to 8 weeks and can include multiple sessions per week. Ebert et al63 (n=108) noted that active knee flexion at the beginning of outpatient visits correlates strongly with knee flexion at 7 weeks after TKA, underscoring the importance of rehabilitation even after hospital discharge. Similarly, Brennan et al64 (n=321) recently reported that an increase in the number of days between hospital discharge and outpatient physical therapy was a significant factor in the prediction of disability and pain scores at the completion of rehabilitation, with an increase in the number of days correlating with an increase in pain and disability. In a survey of physiotherapists concerning best practices for rehabilitation, participants agreed that “aggressive physiotherapy should be met within 8 weeks, as the knee can become stiff as a result of tissue scarring down from lack of mobility.”65
A key research issue, of recent importance due to the increased demands placed on rehabilitation services, has been the use of group physical therapy vs individual physical therapy. Naylor et al66 surveyed 93 TKA patients after their rehabilitation was complete and found no overall preference for either mode. The authors also confirmed the strengths of each mode: group-based therapy granted a psychosocial benefit, whereas the one-to-one therapy offered a more personalized approach. Aprile et al67 conducted a randomized, single-blind, crossover study (n=27) comparing individual and group rehabilitation. They found no significant differences in Short Form-36, WOMAC, and visual analog scale scores between patients at 1 month after TKA.67 Similarly, Ko et al68 conducted a randomized, superiority trial (n=249) comparing one-to-one therapy, group-based therapy, and a monitored home program. They found that “one-to-one therapy does not provide superior self-reported or performance-based outcomes compared with group-based therapy or a monitored home program, in the short term and the long term after total knee arthroplasty.”68 The outcome measures included the Oxford knee score, WOMAC score, and Short Form-12 score.
Outpatient physical therapy remains relevant in the clinical pathway following primary TKA; however, current trends indicate a shift toward patient-specific regimens. Because evidence suggests both group therapy and individual therapy are viable options, patients can be assigned according to their individual preferences concerning physical therapy.
Home Exercises and In-Home Telerehabilitation. Both home exercise regimens delivered via a physician handout containing diagrammed exercises and telerehabilitation involving physical therapists interacting via live, 2-way video feeds have recently garnered attention as resource-saving rehabilitation modalities.
According to Dr Froimson, President of the Cleveland Clinic Health System, “The goals of a home-based clinical care path . . . include patient and family engagement, shared decision-making, and flexibility regarding changes in plans to accommodate changing needs.”69 He continued, “Patients discharged home consume significantly fewer resources and cost the system about one-third as much as those sent to an inpatient postacute facility.” In a recent RCT (n=34), Buker et al70 compared supervised physiotherapy with home exercises. They found no differences in visual analog scale score, ROM, WOMAC score, and Short Form-36 score between the groups and noted that home exercises were approximately $209 less expensive. Similarly, Rajan et al71 randomized patients (n=120) to receive either usual-care physiotherapy or a well-structured home exercise regimen. At 1-year follow-up, only a clinically insignificant difference of 2.9° in ROM was seen. Kramer et al72 randomized patients similarly (n=160) and found no significant differences in Knee Society score, WOMAC score, Short Form-36 score, 6-minute walking test, 30-second stair climbing time, and knee flexion ROM at 3 months and 1 year after TKA. Han et al73 confirmed these findings in a multicenter, noninferiority RCT (n=490). They reported no significant differences in pain, knee function, ROM, or 50-foot walk times at 6 weeks postoperatively. Home-based care, as per current evidence, is a viable and more efficient alternative to outpatient rehabilitation.
Telerehabilitation is a newer medium for postoperative rehabilitation; advances in technology and Internet availability have made wider use of these technologies possible. Russell et al74 conducted an RCT (n=65) evaluating the equivalence of an Internet-based telerehabilitation program with conventional outpatient physical therapy. The authors noted comparable ROM, muscle strength, limb girth, pain, timed up-and-go, quality of life, gait, and WOMAC scores. They also noted that the telerehabilitation intervention was well received by participants, who reported a high level of satisfaction with this novel technology.74 Similarly, a higher-powered RCT (n=205) that compared face-to-face home rehabilitation with telerehabilitation found the latter to be noninferior in terms of WOMAC score, knee injury and osteoarthritis outcome score, knee function, knee strength, and ROM.75 Examining cost concerns, Tousignant et al76 used an RCT (n=197) to compare telerehabilitation with home-visit rehabilitation. The authors found telerehabilitation to be less expensive via a total cost analysis—a differential of -$263 (95% confidence interval, -$382 to -$143) in Canadian dollars.76 However, in lieu of a net analysis, telerehabilitation was only significantly less expensive when the patient lived more than 30 km from the health care center. Telerehabilitation offers yet another way for health care professionals to account for patient-specific factors in prescribing postoperative physical therapy. For patients with the technological accessibility and savvy, a telerehabilitation regimen may be indicated.
Adjunctive Interventions
Neuromuscular Electric Stimulation. In an attempt to improve TKA outcomes, an array of adjunctive interventions is under investigation. Neuromuscular electric stimulation (NEMS) involves electrical stimulation of lower limb muscles using a transcutaneous electrical nerve stimulation system. Neuromuscular electric stimulation is hypothesized to improve muscle strength of the quadriceps and to train patients without sufficient volitional quadriceps activation by engaging neuro-physiological mechanisms after TKA.77
Levine et al,78 in an RCT (n=70), showed that NMES combined with unsupervised at-home exercises was noninferior to traditional supervised physiotherapy at 6 months postoperatively regarding flexion, extension, Knee Society score, WOMAC score, and timed up-and-go. In a small RCT (n=30), Avramidis et al79 applied NMES to the vastus medialis for 6 weeks postoperatively as an adjunct to conventional physical therapy. The authors found a significant increase in walking speed at 3 months, but the Hospital for Special Surgery knee score was unchanged.79 Similarly, Demircioglu et al80 (n=60) applied an adjunctive NMES protocol—5 days a week for 4 to 6 weeks—to a standard exercise protocol in an RCT. They found that NMES improved ROM and timed up-and-go at 1 month but not at 3 months postoperatively. They also measured better WOMAC scores at both 1 and 3 months. The authors concluded that NMES therapy added to a standard exercise protocol offers superior outcomes.80 Although few studies have examined the long-term effects of NMES, in a small RCT (n=35), Stevens-Lapsley et al81 noted that improvements in quadriceps strength, hamstring strength, stair climbing time, timed up-and-go, and 6-minute walking test persisted until 1 year after TKA. In a high-powered RCT (n=200), Petterson et al82 showed that strength, activation, and function were similar between the exercise and exercise–NMES groups at 3 and 12 months. However, both groups were stronger and exhibited better function than the standard-of-care group at both time points.
Overall, NMES is a relatively new modality in the postoperative course of primary TKA. Preliminary evidence suggests a slight improvement in clinical outcomes with the use of NMES.
Wii-Based Home Rehabilitation. Balance training has been included in rehabilitation after TKA.83,84 Given the recent prevalence of Wii (Nintendo, Kyoto, Japan) console systems in homes and the inclusion of Wii Fit, the concept of Wii-based home rehabilitation via balance training has emerged as an adjunct to traditional physiotherapy. Wii Fit games encourage lower extremity movement, challenge balance, and require players to remain in a standing position during play—activities that have the potential to address rehabilitation goals involving recovery of lower extremity function.85 McPhail et al86 (n=18) conducted a preliminary trial in patients recovering from lower limb fractures. The Wii Fit regimen failed to show clinically meaningful differences in a range of measurements, including gait parameters, lower extremity functional scale, and step test.86 Similarly, in an RCT (n=50), Fung et al85 administered 15-minute sessions of Wii Fit after traditional physical therapy sessions. They found no significant differences between the groups regarding pain, knee flexion, knee extension, walking speed, timed standing tasks, lower extremity functional scale, activity-specific balance confidence scale, and patient satisfaction with therapy services.85
Clinical Relevance
In the lengthy clinical pathway from scheduling a patient for TKA to the patient’s resuming normal activity, many options—old and new—exist in the interest of maximizing patient outcome. Overall, evidence seems to suggest that preoperative rehabilitation and education are unsuccessful at enhancing outcomes. Inpatient rehabilitation remains a mainstay before releasing a patient and is effective. Continuous passive motion has been heavily investigated without much consensus, but the current authors’ analysis along with recent evidence supports the conclusion that CPM offers little benefit to primary TKA patients in lieu of standard-of-care physical therapy. Outpatient rehabilitation is incredibly popular. However, given its cost, inconvenience, and increased load on limited health care resources, outpatient rehabilitation is being slowly replaced by unsupervised home exercises and telerehabilitation without any adverse effects. Adjunctive therapies such as NMES have begun to emerge, but their long-term advantage needs to be substantiated. New opportunities such as mobile application–based physical therapy hold promise in enhancing patient satisfaction and reducing health care resource utilization by granting increased autonomy, digitizing patient management, identifying outliers for more intensive therapy, and potentially enhancing outcomes. These new opportunities require further investigation and hold promise for a health care utilization scheme that can adequately manage the increasing demand for TKA services.
References
Steiner C, Andrews R, Barrett M, Weiss A. HCUP projections: mobility/orthopedic procedures 2003 to 2012. https://www.hcup-us.ahrq.gov/reports/projections/2012-03.pdf. Accessed June 17, 2015.
Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007; 89(4):780–785.
NIH Consensus Statement on total knee replacement. NIH Consens State Sci Statements. 2003; 20(1):1–34.
Lingard EA, Berven S, Katz JNKinemax Outcomes Group. Management and care of patients undergoing total knee arthroplasty: variations across different health care settings. Arthritis Care Res. 2000; 13(3):129–136. doi:10.1002/1529-0131(200006)13:33.0.CO;2-6 [CrossRef]
Müller E, Mittag O, Gülich M, Uhlmann A, Jäckel WH. Systematic literature analysis on therapies applied in rehabilitation of hip and knee arthroplasty: methods, results and challenges [in German]. Rehabilitation (Stuttg). 2009; 48(2):62–72. doi:10.1055/s-0029-1202295 [CrossRef]
Bruun-Olsen V, Heiberg KE, Mengshoel AM. Continuous passive motion as an adjunct to active exercises in early rehabilitation following total knee arthroplasty: a randomized controlled trial. Disabil Rehabil. 2009; 31(4):277–283. doi:10.1080/09638280801931204 [CrossRef]
Denis M, Moffet H, Caron F, Ouellet D, Paquet J, Nolet L. Effectiveness of continuous passive motion and conventional physical therapy after total knee arthroplasty: a randomized clinical trial. Phys Ther. 2006; 86(2):174–185.
Chiarello CM, Gundersen L, O’Halloran T. The effect of continuous passive motion duration and increment on range of motion in total knee arthroplasty patients. J Orthop Sports Phys Ther. 1997; 25(2):119–127. doi:10.2519/jospt.1997.25.2.119 [CrossRef]
Lau SK, Chiu KY. Use of continuous passive motion after total knee arthroplasty. J Arthroplasty. 2001; 16(3):336–339. doi:10.1054/arth.2001.21453 [CrossRef]
MacDonald SJ, Bourne RB, Rorabeck CH, McCalden RW, Kramer J, Vaz M. Prospective randomized clinical trial of continuous passive motion after total knee arthroplasty. Clin Orthop Relat Res. 2000; 380:30–35. doi:10.1097/00003086-200011000-00005 [CrossRef]
Montgomery F, Eliasson M. Continuous passive motion compared to active physical therapy after knee arthroplasty: similar hospitalization times in a randomized study of 68 patients. Acta Orthop Scand. 1996; 67(1):7–9. doi:10.3109/17453679608995599 [CrossRef]
Chen B, Zimmerman JR, Soulen L, DeLisa JA. Continuous passive motion after total knee arthroplasty: a prospective study. Am J Phys Med Rehabil. 2000; 79(5):421–426. doi:10.1097/00002060-200009000-00003 [CrossRef]
Johnson DP. The effect of continuous passive motion on wound-healing and joint mobility after knee arthroplasty. J Bone Joint Surg Am. 1990; 72(3):421–426. doi:10.2106/00004623-199072030-00016 [CrossRef]
Maloney WJ, Schurman DJ, Hangen D, Goodman SB, Edworthy S, Bloch DA. The influence of continuous passive motion on outcome in total knee arthroplasty. Clin Orthop Relat Res. 1990; 256:162–168.
Pope RO, Corcoran S, McCaul K, Howie DW. Continuous passive motion after primary total knee arthroplasty: does it offer any benefits?J Bone Joint Surg Br. 1997; 79(6):914–917. doi:10.1302/0301-620X.79B6.7516 [CrossRef]
Beaupre LA, Davies DM, Jones CA, Cinats JG. Exercise combined with continuous passive motion or slider board therapy compared with exercise only: a randomized controlled trial of patients following total knee arthroplasty. Phys Ther. 2001; 81(4):1029–1037.
Mau-Moeller A, Behrens M, Finze S, Bruhn S, Bader R, Mittelmeier W. The effect of continuous passive motion and sling exercise training on clinical and functional outcomes following total knee arthroplasty: a randomized active-controlled clinical study. Health Qual Life Outcomes. 2014; 12:68. doi:10.1186/1477-7525-12-68 [CrossRef]
Herbold JA, Bonistall K, Blackburn M, et al. . Randomized controlled trial of the effectiveness of continuous passive motion after total knee replacement. Arch Phys Med Rehabil. 2014; 95(7):1240–1245. doi:10.1016/j.apmr.2014.03.012 [CrossRef]
Chen LH, Chen CH, Lin SY, et al. . Aggressive continuous passive motion exercise does not improve knee range of motion after total knee arthroplasty. J Clin Nurs. 2013; 22(3–4):389–394. doi:10.1111/j.1365-2702.2012.04106.x [CrossRef]
Lenssen TA, van Steyn MJ, Crijns YH, et al. . Effectiveness of prolonged use of continuous passive motion (CPM), as an adjunct to physiotherapy, after total knee arthroplasty. BMC Musculoskelet Disord. 2008; 9:60. doi:10.1186/1471-2474-9-60 [CrossRef]
Worland RL, Arredondo J, Angles F, Lopez-Jimenez F, Jessup DE. Home continuous passive motion machine versus professional physical therapy following total knee replacement. J Arthroplasty. 1998; 13(7):784–787. doi:10.1016/S0883-5403(98)90031-6 [CrossRef]
Joshi RN, White PB, Murray-Weir M, Alexiades MM, Sculco TP, Ranawat AS. Prospective randomized trial of the efficacy of continuous passive motion post total knee arthroplasty: experience of the Hospital for Special Surgery. J Arthroplasty. 2015; 30(12):2364–2369. doi:10.1016/j.arth.2015.06.006 [CrossRef]
Bennett LA, Brearley SC, Hart JA, Bailey MJ. A comparison of 2 continuous passive motion protocols after total knee arthroplasty: a controlled and randomized study. J Arthroplasty. 2005; 20(2):225–233. doi:10.1016/j.arth.2004.08.009 [CrossRef]
Colwell CW Jr, Morris BA. The influence of continuous passive motion on the results of total knee arthroplasty. Clin Orthop Relat Res. 1992; 276:225–228.
Kumar PJ, McPherson EJ, Dorr LD, Wan Z, Baldwin K. Rehabilitation after total knee arthroplasty: a comparison of 2 rehabilitation techniques. Clin Orthop Relat Res. 1996; 331:93–101. doi:10.1097/00003086-199610000-00013 [CrossRef]
Maniar RN, Baviskar JV, Singhi T, Rathi SS. To use or not to use continuous passive motion post-total knee arthroplasty presenting functional assessment results in early recovery. J Arthroplasty. 2012; 27(2):193–200. doi:10.1016/j.arth.2011.04.009 [CrossRef]
Johnson DP, Eastwood DM. Beneficial effects of continuous passive motion after total condylar knee arthroplasty. Ann R Coll Surg Engl. 1992; 74(6):412–416.
Leach W, Reid J, Murphy F. Continuous passive motion following total knee replacement: a prospective randomized trial with follow-up to 1 year. Knee Surg Sports Traumatol Arthrosc. 2006; 14(10):922–926. doi:10.1007/s00167-006-0042-9 [CrossRef]
Alkire MR, Swank ML. Use of inpatient continuous passive motion versus no CPM in computer-assisted total knee arthroplasty. Orthop Nurs. 2010; 29(1):36–40. doi:10.1097/NOR.0b013e3181c8ce23 [CrossRef]
Boese CK, Weis M, Phillips T, Lawton-Peters S, Gallo T, Centeno L. The efficacy of continuous passive motion after total knee arthroplasty: a comparison of three protocols. J Arthroplasty. 2014; 29(6):1158–1162. doi:10.1016/j.arth.2013.12.005 [CrossRef]
McInnes J, Larson MG, Daltroy LH, et al. . A controlled evaluation of continuous passive motion in patients undergoing total knee arthroplasty. JAMA. 1992; 268(11):1423–1428. doi:10.1001/jama.268.11.1423 [CrossRef]
Nielsen PT, Rechnagel K, Nielsen SE. No effect of continuous passive motion after arthroplasty of the knee. Acta Orthop Scand. 1988; 59(5):580–581. doi:10.3109/17453678809148789 [CrossRef]
Walker RH, Morris BA, Angulo DL, Schneider J, Colwell CW Jr, . Postoperative use of continuous passive motion, transcutaneous electrical nerve stimulation, and continuous cooling pad following total knee arthroplasty. J Arthroplasty. 1991; 6(2):151–156. doi:10.1016/S0883-5403(11)80010-0 [CrossRef]
Herbold JA, Bonistall K, Blackburn M. Effectiveness of continuous passive motion in an inpatient rehabilitation hospital after total knee replacement: a matched cohort study. PM R. 2012; 4(10):719–725. doi:10.1016/j.pmrj.2012.07.004 [CrossRef]
Oshodi TO. The impact of preoperative education on postoperative pain: Part 2. Br J Nurs. 2007; 16(13):790–797. doi:10.12968/bjon.2007.16.13.24244 [CrossRef]
Oshodi TO. The impact of preoperative education on postoperative pain: Part 1. Br J Nurs. 2007; 16(12):706–710. doi:10.12968/bjon.2007.16.12.23719 [CrossRef]
Hathaway D. Effect of preoperative instruction on postoperative outcomes: a meta-analysis. Nurs Res. 1986; 35(5):269–275. doi:10.1097/00006199-198609000-00004 [CrossRef]
Louw A, Diener I, Butler DS, Puentedura EJ. Preoperative education addressing postoperative pain in total joint arthroplasty: review of content and educational delivery methods. Physiother Theory Pract. 2013; 29(3):175–194. doi:10.3109/09593985.2012.727527 [CrossRef]
Chen SR, Chen CS, Lin PC. The effect of educational intervention on the pain and rehabilitation performance of patients who undergo a total knee replacement. J Clin Nurs. 2014; 23(1–2):279–287. doi:10.1111/jocn.12466 [CrossRef]
Crowe J, Henderson J. Pre-arthroplasty rehabilitation is effective in reducing hospital stay. Can J Occup Ther. 2003; 70(2):88–96. doi:10.1177/000841740307000204 [CrossRef]
Aydin D, Klit J, Jacobsen S, Troelsen A, Husted H. No major effects of preoperative education in patients undergoing hip or knee replacement: a systematic review. Dan Med J. 2015; 62(7):A5106.
Ditmyer MM, Topp R, Pifer M. Prehabilitation in preparation for orthopaedic surgery. Orthop Nurs. 2002; 21(5):43–51. doi:10.1097/00006416-200209000-00008 [CrossRef]
Williamson L, Wyatt MR, Yein K, Melton JT. Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement. Rheumatology (Oxford). 2007; 46(9):1445–1449. doi:10.1093/rheumatology/kem119 [CrossRef]
Mitchell C, Walker J, Walters S, Morgan AB, Binns T, Mathers N. Costs and effectiveness of pre- and post-operative home physiotherapy for total knee replacement: randomized controlled trial. J Eval Clin Pract. 2005; 11(3):283–292. doi:10.1111/j.1365-2753.2005.00535.x [CrossRef]
Matassi F, Duerinckx J, Vandenneucker H, Bellemans J. Range of motion after total knee arthroplasty: the effect of a preoperative home exercise program. Knee Surg Sports Traumatol Arthrosc. 2014; 22(3):703–709. doi:10.1007/s00167-012-2349-z [CrossRef]
Beaupre LA, Lier D, Davies DM, Johnston DB. The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty. J Rheumatol. 2004; 31(6):1166–1173.
Kwok IH, Paton B, Haddad FS. Does preoperative physiotherapy improve outcomes in primary total knee arthroplasty? A systematic review. J Arthroplasty. 2015; 30(9):1657–1663. doi:10.1016/j.arth.2015.04.013 [CrossRef]
Gill SD, McBurney H. Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. 2013; 94(1):164–176. doi:10.1016/j.apmr.2012.08.211 [CrossRef]
Wallis JA, Taylor NF. Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2011; 19(12):1381–1395. doi:10.1016/j.joca.2011.09.001 [CrossRef]
D’Lima DD, Colwell CW Jr, Morris BA, Hardwick ME, Kozin F. The effect of preoperative exercise on total knee replacement outcomes. Clin Orthop Relat Res. 1996; 326:174–182. doi:10.1097/00003086-199605000-00020 [CrossRef]
Coudeyre E, Jardin C, Givron P, Ribinik P, Revel M, Rannou F. Could preoperative rehabilitation modify postoperative outcomes after total hip and knee arthroplasty? Elaboration of French clinical practice guidelines. Ann Readapt Med Phys. 2007; 50(3):189–197. doi:10.1016/j.annrmp.2007.02.002 [CrossRef]
Pua YH, Ong PH. Association of early ambulation with length of stay and costs in total knee arthroplasty: retrospective cohort study. Am J Phys Med Rehabil. 2014; 93(11):962–970. doi:10.1097/PHM.0000000000000116 [CrossRef]
Zietek P, Zietek J, Szczypior K, Safranow K. Effect of adding one 15-minute-walk on the day of surgery to fast-track rehabilitation after total knee arthroplasty: a randomized, single-blind study. Eur J Phys Rehabil Med. 2015; 51(3):245–252.
Lenssen AF, Crijns YH, Waltjé EM, et al. . Efficiency of immediate postoperative inpatient physical therapy following total knee arthroplasty: an RCT. BMC Musculoskelet Disord. 2006; 7:71. doi:10.1186/1471-2474-7-71 [CrossRef]
Isaac D, Falode T, Liu P, I’Anson H, Dillow K, Gill P. Accelerated rehabilitation after total knee replacement. Knee. 2005; 12(5):346–350. doi:10.1016/j.knee.2004.11.007 [CrossRef]
Doman DM, Gerlinger TL. Total joint arthroplasty cost savings with a rapid recovery protocol in a military medical center. Mil Med. 2012; 177(1):64–69. doi:10.7205/MILMED-D-11-00163 [CrossRef]
Vince KG, Kelly MA, Beck J, Insall JN. Continuous passive motion after total knee arthroplasty. J Arthroplasty. 1987; 2(4):281–284. doi:10.1016/S0883-5403(87)80060-8 [CrossRef]
Lenssen AF, Crijns YH, Waltjé EM, et al. . Effectiveness of prolonged use of continuous passive motion (CPM) as an adjunct to physiotherapy following total knee arthroplasty: design of a randomised controlled trial [ISRCTN85759656]. BMC Musculoskelet Disord. 2006; 7:15. doi:10.1186/1471-2474-7-15 [CrossRef]
Brosseau L, Milne S, Wells G, et al. . Efficacy of continuous passive motion following total knee arthroplasty: a metaanalysis. J Rheumatol. 2004; 31(11):2251–2264.
Milne S, Brosseau L, Robinson V, et al. . Continuous passive motion following total knee arthroplasty. Cochrane Database Syst Rev.2003; 2:CD004260.
He ML, Xiao ZM, Lei M, Li TS, Wu H, Liao J. Continuous passive motion for preventing venous thromboembolism after total knee arthroplasty. Cochrane Database Syst Rev.2014; 7:CD008207.
Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in people with arthritis. Cochrane Database Syst Rev.2010; 3:CD004260.
Ebert JR, Munsie C, Joss B. Guidelines for the early restoration of active knee flexion after total knee arthroplasty: implications for rehabilitation and early intervention. Arch Phys Med Rehabil. 2014; 95(6):1135–1140. doi:10.1016/j.apmr.2014.02.015 [CrossRef]
Brennan GP, Fritz JM, Houck LT, Hunter SJ. Outpatient rehabilitation care process factors and clinical outcomes among patients discharged home following unilateral total knee arthroplasty. J Arthroplasty. 2015; 30(5):885–890. doi:10.1016/j.arth.2014.12.013 [CrossRef]
Majumdar SS, Luccisano M, Evans C. Perceptions of physiotherapy best practice in total knee arthroplasty in hospital outpatient settings. Physiother Can. 2011; 63(2):234–241. doi:10.3138/ptc.2010-09 [CrossRef]
Naylor JM, Mittal R, Carroll K, Harris IA. Introductory insights into patient preferences for outpatient rehabilitation after knee replacement: implications for practice and future research. J Eval Clin Pract. 2012; 18(3):586–592. doi:10.1111/j.1365-2753.2010.01619.x [CrossRef]
Aprile I, Rizzo RS, Romanini E, et al. . Group rehabilitation versus individual rehabilitation following knee and hip replacement: a pilot study with randomized, single-blind, crossover design. Eur J Phys Rehabil Med. 2011; 47(4):551–559.
Ko V, Naylor J, Harris I, Crosbie J, Yeo A, Mittal R. One-to-one therapy is not superior to group or home-based therapy after total knee arthroplasty: a randomized, superiority trial. J Bone Joint Surg Am. 2013; 95(21):1942–1949. doi:10.2106/JBJS.L.00964 [CrossRef]
Froimson MI. In-home care following total knee replacement. Cleve Clin J Med. 2013; 80(suppl 1):eS15–eS18. doi:10.3949/ccjm.80.e-s1.04 [CrossRef]
Buker N, Akkaya S, Akkaya N, et al. . Comparison of effects of supervised physiotherapy and a standardized home program on functional status in patients with total knee arthroplasty: a prospective study. J Phys Ther Sci. 2014; 26(10):1531–1536. doi:10.1589/jpts.26.1531 [CrossRef]
Rajan RA, Pack Y, Jackson H, Gillies C, Asirvatham R. No need for outpatient physiotherapy following total knee arthroplasty: a randomized trial of 120 patients. Acta Orthop Scand. 2004; 75(1):71–73. doi:10.1080/00016470410001708140 [CrossRef]
Kramer JF, Speechley M, Bourne R, Rorabeck C, Vaz M. Comparison of clinic- and home-based rehabilitation programs after total knee arthroplasty. Clin Orthop Relat Res. 2003; 410:225–234. doi:10.1097/01.blo.0000063600.67412.11 [CrossRef]
Han AS, Nairn L, Harmer AR, et al. . Early rehabilitation after total knee replacement surgery: a multicenter, noninferiority, randomized clinical trial comparing a home exercise program with usual outpatient care. Arthritis Care Res (Hoboken). 2015; 67(2):196–202. doi:10.1002/acr.22457 [CrossRef]
Russell TG, Buttrum P, Wootton R, Jull GA. Internet-based outpatient telerehabilitation for patients following total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am. 2011; 93(2):113–120. doi:10.2106/JBJS.I.01375 [CrossRef]
Moffet H, Tousignant M, Nadeau S, et al. . In-home telerehabilitation compared with face-to-face rehabilitation after total knee arthroplasty: a noninferiority randomized controlled trial. J Bone Joint Surg Am. 2015; 97(14):1129–1141. doi:10.2106/JBJS.N.01066 [CrossRef]
Tousignant M, Moffet H, Nadeau S, et al. . Cost analysis of in-home telerehabilitation for post-knee arthroplasty. J Med Internet Res. 2015; 17(3):e83. doi:10.2196/jmir.3844 [CrossRef]
Kittelson AJ, Stackhouse SK, Stevens-Lapsley JE. Neuromuscular electrical stimulation after total joint arthroplasty: a critical review of recent controlled studies. Eur J Phys Rehabil Med. 2013; 49(6):909–920.
Levine M, McElroy K, Stakich V, Cicco J. Comparing conventional physical therapy rehabilitation with neuromuscular electrical stimulation after TKA. Orthopedics. 2013; 36(3):e319–e324. doi:10.3928/01477447-20130222-20 [CrossRef]
Avramidis K, Strike PW, Taylor PN, Swain ID. Effectiveness of electric stimulation of the vastus medialis muscle in the rehabilitation of patients after total knee arthroplasty. Arch Phys Med Rehabil. 2003; 84(12):1850–1853. doi:10.1016/S0003-9993(03)00429-5 [CrossRef]
Demircioglu DT, Paker N, Erbil E, Bugdayci D, Emre TY. The effect of neuromuscular electrical stimulation on functional status and quality of life after knee arthroplasty: a randomized controlled study. J Phys Ther Sci. 2015; 27(8):2501–2506. doi:10.1589/jpts.27.2501 [CrossRef]
Stevens-Lapsley JE, Balter JE, Wolfe P, Eckhoff DG, Kohrt WM. Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial. Phys Ther. 2012; 92(2):210–226. doi:10.2522/ptj.20110124 [CrossRef]
Petterson SC, Mizner RL, Stevens JE, et al. . Improved function from progressive strengthening interventions after total knee arthroplasty: a randomized clinical trial with an imbedded prospective cohort. Arthritis Rheum. 2009; 61(2):174–183. doi:10.1002/art.24167 [CrossRef]
Peter WF, Nelissen RG, Vlieland TP. Guideline recommendations for post-acute postoperative physiotherapy in total hip and knee arthroplasty: are they used in daily clinical practice?Musculoskeletal Care. 2014; 12(3):125–131. doi:10.1002/msc.1067 [CrossRef]
Piva SR, Gil AB, Almeida GJ, DiGioia AM III, Levison TJ, Fitzgerald GK. A balance exercise program appears to improve function for patients with total knee arthroplasty: a randomized clinical trial. Phys Ther. 2010; 90(6):880–894. doi:10.2522/ptj.20090150 [CrossRef]
Fung V, Ho A, Shaffer J, Chung E, Gomez M. Use of Nintendo Wii Fit in the rehabilitation of outpatients following total knee replacement: a preliminary randomised controlled trial. Physiotherapy. 2012; 98(3):183–188. doi:10.1016/j.physio.2012.04.001 [CrossRef]
McPhail SM, O’Hara M, Gane E, Tonks P, Bullock-Saxton J, Kuys SS. Nintendo Wii Fit as an adjunct to physiotherapy following lower limb fractures: preliminary feasibility, safety and sample size considerations. Physiotherapy. 2016; 102(2):217–220. doi:10.1016/j.physio.2015.04.006 [CrossRef]
Authors
The authors are from the Albert Einstein College of Medicine (MGJ), Bronx, New York; and Stanford University School of Medicine (SB, DFA), Redwood City, California.
Mr Joice and Dr Bhowmick have no relevant financial relationships to disclose. Dr Amanatullah is a paid consultant for Omni, Exactech, Blue-Jay Mobile Health, Stryker, Medscape, and Sanofi and has received grants from BlueJay Mobile Health and Stryker.
Correspondence should be addressed to: Derek F. Amanatullah, MD, PhD, Stanford University School of Medicine, 450 Broadway St, M/C 6342, Pavilion C, 4th Fl, Redwood City, CA 94063 ( dfa@stanford.edu).
Copyright 2017, SLACK Incorporated
Received: June 16, 2016
Accepted: October 31, 2016
10.3928/01477447-20170518-03