Physiotherapy after TKA (total knee arthroplasty)

Physiotherapy after TKA is one of the most important factors that ensure a quick and
complete recovery of a patient. Its significance cannot be underestimated as it is these set
of exercises done in a systematic manner under the guidance of an expert, that helps
patient to resume his pre-diseased condition of the knee, and hence improves the quality
of life to a great extent.

Dr Surender did his B,P,T, and Masters in Physiotherapy ( Musculoskeletal) from PGI ,
Rohtak, and was associated with WHO , posted in Colombo for sometime, got associated
with AIIMS for 2 years, and now working with Nova. He has been working as a
successful physiotherapist for 9 years. Here are some inputs from Dr Surender about the
Physiotherapy after TKA.

The importance of physiotherapy after TKA can be estimated by the fact that it has been
made mandatory for every TKA patient to have physiotherapy sessions. It is a integral
part of rehabilitation of a TKA patient and ideally it should begin from the day of
consultation when the decision of surgery is made. It is of the paramount importance
following total joint replacement in order to achieve the goal of a hassle-free function of
the joint and improve the patient's quality of life.

Dr. Surender explains that resuming the normal state of joints, technically means –
• Resuming of the normal range of motion (ROM) - Normally in a pre-op
state, patients usually do not have ROM that is more than 90 which
increases to 115-125 degrees which is quiet good for the flexibility of a
knee.
• to strengthen the muscles around the knee joint, to increase the endurance
of the knee,
• to be able to have a pain free, fear free, properly coordinated, balanced
gait,
• ability to do the daily activities like climbing stairs which was restricted
due to the pain and swelling around the knee, driving a car.

The schedule provided to the patients, vary as per the post-op condition and the
progress of the healing process which varies from patient to patient. Normally, to start
with there are 2 sessions in a day, each of 30 mins to an 45 minute duration, which
gradually reduces to one session per day for next 6 weeks. This is further reduced to
2- 3 sessions in a week for another few weeks. The total time period for which
physiotherapy is given, is around 8 weeks. The idea is to make patient resume his
normal healthy state of living, which he/she enjoyed even before the appearance of
the symptoms of knee deterioration. A physiotherapist’s aim is to make the patient
fully confident and independent of any assistance for his routine activities.
Ideally, the physiotherapy should start from the day of decision of surgery. In this
pre-op physio session, a patient is informed about the significance of physiotherapy
after the surgery and its role in ensuring the success of the operation. He/she is
familiarized to the regime that will be followed once the surgery is done. This
counseling is important for encouraging the patient to religiously follow the regime
as, there is some post-surgical pain and swelling and patients tend to be reluctant in
taking the initiative of making any movements on the operated knee. The chances of
any mishaps during the post op rehab are minimized as the patient is made aware of
all the do’s and don’ts in the pre-op sessions. Pre-op physiotherapy also aims at
building up the strength of the quadriceps muscles which support the knee and also
helps to increase the stamina in general, so that patient does not feel the exertion
while performing the exercises in the post op sessions. Weight training if needed, is
also initiated during the pre-op physio. In Nova rehabilitation center, patient have the
full benefit of “Advanced Rehabilitation Program” followed after knee replacements.
As the stay is shorter because of the excellant services at Nova , the pre-op physio can
be shortened to 2-3 days.

Once a patient undergo surgery he has a clear idea about the significance of the
physiotherapy treatment, it helps to keep him in a positive mindset and encourage him
to follow the protocol that is handed over to him/her at the time of discharge. The
protocol has a list of exercises in sequence with some pictures to clearly show the
method of doing them.

Normally there are 2 sessions per day to begin with or 3 sessions as per the surgeon’s
choice, which later on reduce to one per day and later on twice or thrice a week. The
patient is asked to perform the exercises before having meals or after 3 hours of
having meals just as in any other workout schedule, says Dr. Surender.

Isometric exercises for knee are very important. The whole idea is to strengthen the
muscles that are supporting the knee. Outcome of the surgery also depends on the
effectiveness of the physiotherapy services followed after the TKR.

There are 9 sets of exercises that are followed as home programme for patient. These
are

• Heel slide – done lying on the back, where the knee is flexed while sliding
the heel on the surface and held for 3-4 secs
• Quad sets – with a rolled towel under the knee, pressing downwards and
tightening the knee with heel raised by 1 inch off the surface
• Short Arc quad sets – with bolster under knee, raising the foot and
straightening the knee.
 • Straight leg raise - raising the leg towards ceiling, keeping the knee
straight.
• Posterior knee stretch - keeping the rolled towel under the heel, pressing
the back of the knee towards the surface.
• Knee extension – begin with the foot placed flat on the surface with knee
bent, raising the leg slowly straightening the leg.
• Dorsal planter flexion – keeping both the feet on the floor, raising the toes
while heels stay touched on the floor and then vice versa.
• Gluteal sets - recline on the back with support on the elbows, squeeze the
buttocks as tight as possible and hold for 5-6 seconds.
• Single leg standing: standing over one leg for 10 secounds each to regain
balance & coordination.

Every patient is unique when it comes to the pace of recovery. Well informed and
positive patients have been observed to have a faster recovery as compared to the
otherwise. Dr. Surender adds that there are certain conditions that commonly
contribute in making changes to the normal schedule. Namely -
• Instability present around the knee in the pre op state can also be due to
the weak ligaments, or torn ligaments apart from the diseased knee like
OA knee. . In these cases, flexion range of the knee is limited by putting a
brace which is locked at say 30 degrees so that the knee does not flex
further. This is done for initial few weeks which is an additional
intervention, done apart from the routine physiotherapy.
• In case of pre-op deformities like valgus and varus, although they are
corrected along with the knee replacement, physiotherapist has to deviate
from the standard protocol and alteration in the rehab program is done to
suit the conditions.

• Sometimes patients buckle the knee while walking, which is strictly

prohibited. This causes pain and swelling on the knee which is then taken
care of.

Domiciliary physiotherapy services are provided to the patients. Expert from the team
visits the patient in his place and ensures that he/she gets the full session for 45 mins
to an hour per day for first few weeks which reduce to few sessions a week and later
on for once every 10 days. The intensity of the exercise increases as the time passes.
 Clear instructions are given to the patient regarding the dos and don’ts. The correct
posture of lying in bed or using the cane or walker for walking is explained to the patient.
Certain vital tips regarding the climbing upstairs or descending downstairs are given to
the patient. Everything related to the routine activities is explained in the protocol as well,
along with pictures.

There are certain activities that are strictly prohibited after the operation as they put a bad
effect on the operated knee. For example -
• No putting pillow under the knee which can cause the tightening of
hamstring muscles because of flexion of the knee.
• No sitting cross-legged or squatting.
• Sudden turn or twisting around the knee is not allowed for initial few
months.

A TKA patient resumes to his normal life after a successful physiotherapy

programme. The quality of life improves in exponential order although certain
activities are forbidden for a life long period. Such people can go for recreational
sports but can never go back to any kind of competitive ones. Similarly professional
dancers need to be very cautious in attempting any form as fast turning or twisting of
knee is completely prohibited.