Accepted Manuscript

Title: Active physiotherapy interventions following total knee

arthroplasty in the hospital and inpatient rehabilitation
settings. A systematic review and meta-analysis

Authors: Kate Georgina Henderson, Jason A. Wallis, David A.

Snowdon

PII: S0031-9406(17)30003-2
DOI: http://dx.doi.org/doi:10.1016/j.physio.2017.01.002
Reference: PHYST 950

To appear in: Physiotherapy

Please cite this article as: Henderson Kate Georgina, Wallis Jason A, Snowdon
David A.Active physiotherapy interventions following total knee arthroplasty in
the hospital and inpatient rehabilitation settings.A systematic review and meta-
analysis.Physiotherapy http://dx.doi.org/10.1016/j.physio.2017.01.002

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Title: Active physiotherapy interventions following total knee arthroplasty in the hospital and

inpatient rehabilitation settings. A systematic review and meta-analysis.

Authors:

1. Kate Georgina Hendersona *

a
Eastern Health Physiotherapy Department. Angliss Hospital, 39 Albert Street, Upper

Ferntree Gully, VIC, Australia 3156

kgforsyth@gmail.com, kate.forsyth@monashhealth.org.au

2. Jason A. Wallisb
b
Eastern Health Physiotherapy Department. Box Hill Hospital, 8 Arnold Street Box Hill VIC,

Australia 3128

jason.wallis@easternhealth.org.au

3. David A. Snowdonc
c
Eastern Health Physiotherapy Department. Box Hill Hospital, 8 Arnold Street Box Hill VIC

Australia 3128

david.snowdon@easternhealth.org.au

Corresponding author:

Mrs. Kate Georgina Henderson, Dandenong Hospital, Physiotherapy Department, Allied Health

Reception ,135 David Street, Dandenong, VIC 3175Australia

Phone: +613 9554 9282

Fax: +613 9554 9038

E-mail: kgforsyth@gmail.com<mailto:kgforsyth@gmail.com>

Postal address: Dandenong Hospital, 135 David Street, Dandenong VIC Australia 3175

*
Present address Dandenong Hospital, 135 David Street, Dandenong Vic Australia 3175

Physiotherapy interventions after total knee arthroplasty Page 1 of 28

ABSTRACT

Background: Physiotherapy is a routine component of post-operative management following

total knee arthroplasty (TKA). As the demand for surgery increases it is vital that post-

operative physiotherapy interventions are effective and efficient.

Objectives: Determine the most beneficial active physiotherapy interventions in acute

hospital and inpatient rehabilitation for improving pain, activity, range of motion and

reducing length of stay for adults who have undergone TKA.

Data sources: Electronic databases MEDLINE, CINAHL, PUBMED and EMBASE.

Study eligibility criteria: Randomised controlled trials investigating the effect of active

physiotherapy interventions in the acute hospital or inpatient rehabilitation setting for adults

who have undergone TKA.

Study appraisal and synthesis methods: Risk of bias for individual studies was assessed

using the Physiotherapy Evidence Database (PEDro) scale. Standardised Mean Differences

(SMD) or Mean Differences (MD) and 95% confidence intervals were calculated and

combined in meta-analyses. Quality of meta-analyses was assessed using the Grades of

Research, Assessment, Development and Evaluation approach.

Results: Accelerated physiotherapy regimens were effective for reducing acute hospital

length of stay (MD -3.5 days, 95% CI -5.7 to -1.3). Technology-assisted physiotherapy did

not show any difference for activity (SMD -0.34, 95% CI -0.82 to 0.13). From high quality

individual studies pain, activity and range of motion improved with accelerated physiotherapy

regimens and activity improved with hydrotherapy.

Limitations: Lack of blinding and small sample sizes across the included trials.

Conclusion: After TKA, there is low level evidence that accelerated physiotherapy regimens

can reduce acute hospital length of stay.

Systematic review registration number: PROSPERO registration number

Physiotherapy interventions after total knee arthroplasty Page 2 of 28

CRD42014013414 http://www.crd.york.ac.uk/PROSPERO.

Contribution of the Paper:

 The most important role of physiotherapists in the management of patients following

TKA is facilitating mobilisation within 48 hours of surgery, as part of an accelerated

pathway.

 Physiotherapy in the hospital and inpatient rehabilitation settings following TKA

should be focused on activity-based interventions.

 Further research is required to establish the effect of impairment-based interventions

in the hospital and inpatient rehabilitation settings following TKA.

Key words: Total knee arthroplasty; physiotherapy specialty; physiotherapy techniques;

hydrotherapy; rehabilitation

INTRODUCTION

Total knee arthroplasty (TKA) is a cost effective intervention for end-stage knee

osteoarthritis, with demonstrable benefits for improving pain, activity and quality of life [1,

2]. As the population ages, it is anticipated the number of people electing for TKA will

continue to rise [3], consequently placing an increasing burden on health care systems.

Physiotherapists play a role in the acute hospital and inpatient rehabilitation settings by

facilitating independence in transfers and ambulation, and achieving functional goals for

people after TKA. Despite trend to very early discharge after TKA [4], the average hospital

length of stay (LOS) following TKA is reported as 5.5 days (range 2.1 to 9.5 days) in

Australia [5] and 6.6 days in the United Kingdom [6]. It is therefore essential that

Physiotherapy interventions after total knee arthroplasty Page 3 of 28

physiotherapy interventions provided in the acute and inpatient rehabilitation settings are

worthwhile and efficient in producing these important patient outcomes, in order to further

minimise LOS and health care costs. However, there are currently no evidence-based

guidelines in these settings to advise the most effective physiotherapy interventions following

TKA, including the type, timing, and dosage of interventions [3, 7].

Two systematic reviews [8, 9] investigating TKA rehabilitation in the outpatient setting have

been conducted. The first, a systematic review [8] and meta-analysis of six trials

demonstrated small to moderate benefits for activity with physiotherapy interventions

involving mostly functional exercises (SMD 0.33, 95% CI 0.07 to 0.58). The second

systematic review [9] of 19 trials concluded physiotherapy should comprise strengthening and

intensive functional exercises delivered via land-based or aquatic programs.

Therefore, the research question of this systematic review was what are the most beneficial

active physiotherapy interventions and regimens in acute hospital and inpatient rehabilitation

for improving pain, activity, range of motion (ROM) and reducing LOS for adults who have

undergone TKA?

METHOD

Search strategy

The electronic databases MEDLINE, CINAHL, PUBMED and EMBASE were searched from

earliest available time until July 2014. The concepts of population, intervention, outcome and

design were combined with the ‘AND’ operator. Population was defined as participants who

had a TKA. Intervention was defined as any form of active physiotherapy in an acute hospital

or inpatient rehabilitation setting following TKA. Primary outcomes were pain, activity and

Physiotherapy interventions after total knee arthroplasty Page 4 of 28

LOS. Knee ROM was the secondary outcome. The design was randomised controlled trials.

Synonyms were searched for each concept and combined with the ‘OR’ operator (Appendix

1).

All articles were imported to bibliographic software and screened for duplicates. Two

reviewers independently screened title and abstract of each article using pre-determined

eligibility criteria. Discrepancies were resolved via discussion. Full text copies were retrieved

for articles that were not excluded based on title and abstract and eligibility criteria applied by

the same reviewers. Disagreements unable to be resolved via discussion were taken to a third

reviewer to achieve consensus. Reference lists of included articles were hand-searched and

citation tracking applied using Google Scholar to identify any further articles for inclusion.

Eligibility criteria

The review included randomised trials if at least 85% of the sample had a primary TKA due

to osteoarthritis, the outcomes included at least one of pain, activity or LOS, and the

experimental intervention involved any form of active physiotherapy intervention, such as

strengthening or active ROM, performed in an acute hospital or inpatient rehabilitation

setting. Studies investigating the effects of passive interventions such as continuous passive

motion or manual therapies, could only be included if the passive modality was not the

primary difference between the therapy provided to experimental and control groups. Studies

that included neuromuscular electrical stimulation were considered passive if the participant

was not required to produce a voluntary contraction of the muscle prior to the device

delivering electrical stimulation. The comparison intervention was standard physiotherapy,

defined as usual physiotherapy management in acute hospital or rehabilitation, or another

form of active physiotherapy intervention. Studies that compared two or more different

Physiotherapy interventions after total knee arthroplasty Page 5 of 28

regimens of exercise were also included to investigate the ideal intensity and postoperative

commencement of exercise. Studies were excluded if the samples included participants who

had a unicompartmental knee arthroplasty or revision TKA. Studies that included participants

with total hip arthroplasty and TKA and did not report outcomes separately were also

ineligible. Studies written in languages other than English were excluded.

Data collection and analysis

A pre-designed data collection form was used to extract data on participants, setting,

interventions, outcome measures and results. Investigators were contacted to confirm data

where required. SMDs and 95% confidence intervals were calculated from post-intervention

means and standard deviations for pain and activity outcomes. Mean differences (MD) and

95% confidence intervals were calculated for LOS and ROM outcomes. P-values were used

to estimate standard deviations where these data were not reported. Mean values were

extrapolated from graphs if not reported elsewhere in the article. Medians were converted to

means where required [10]. Effect sizes of <0.2 were considered small, 0.5 considered

moderate and >0.8 considered a large effect size [11]. A negative SMD or MD indicated that

the outcome favoured the intervention group for activity, pain and LOS measures. A positive

MD indicated that the outcome measure favoured the intervention group in ROM. Studies

were grouped according to similar interventions for analysis purposes. ‘Accelerated

physiotherapy’ was defined as physiotherapy intervention commencing within 24 hours of

surgery, and occurring more than 24 hours prior to standard care. ‘Technology-assisted

physiotherapy’ was defined as physiotherapy intervention delivered via use of a robotic

training system or computer-based electronic device. Meta-analyses were conducted if two or

more studies were clinically homogeneous, where common population, intervention and

outcome measures were used. Meta-analyses were performed using the inverse variance

Physiotherapy interventions after total knee arthroplasty Page 6 of 28

method and random effects model [12]. Studies that did not demonstrate sufficient clinical

homogeneity to be combined in meta-analyses were reported in tables and descriptive format.

Risk of bias

The risk of bias of each study was assessed by two reviewers independently using the

Physiotherapy Evidence Database (PEDro) scale [13]. The eleven items of the scale were

scored ‘yes’ or ‘no’. The maximum score is 10 as the first item of the scale is not counted. A

score of 6 or more was considered high quality [14]. Results of the reviewers were compared

and discrepancies resolved via discussion using the PEDro operational definitions. Agreement

between assessors was calculated using kappa coefficient.

The quality of evidence of the meta-analyses performed was assessed using the Grades of

Research, Assessment, Development and Evaluation (GRADE) approach [15]. This approach

specifies that a body of evidence can be downgraded from high quality evidence, based on

four criteria: (1) risk of bias across studies (downgrade if average PEDro score was <6 for

studies included in the meta-analysis); (2) inconsistency of results (downgrade if I2 >50%

indicating high statistical heterogeneity between the studies); (3) indirectness of results

(downgrade if indirect comparisons between interventions or outcomes); (4) imprecision of

results (downgrade if large confidence intervals, defined as > 0.8 for standardised mean

differences (SMD) or mean differences (MD)).

RESULTS

Flow of studies through the review

The database search yielded 1019 trials. The eligibility criteria were applied to title and

abstract, excluding 978 trials. Full texts of the remaining forty-one trials were retrieved. The

Physiotherapy interventions after total knee arthroplasty Page 7 of 28

eligibility criteria were then applied to full texts. Twelve trials fulfilled the inclusion criteria.

No trials were identified from reference lists of included articles or citation tracking. Two

trials reported results using the same data and were therefore considered one trial in this

review. The final yield was 11 trials (Figure 1).

Characteristics of studies

Risk of bias

Eight trials were rated as having a low risk of bias and the average PEDro score across all

trials was 6/10 (range 3 to 8) [interrater agreement κ = 0.86 (95% CI 0.76 to 0.95)] (Table 1).

Most adhered to the items of random allocation, between group comparison, measure of

variability and specification of eligibility criteria. None adhered to the ‘blinded participants’

or ‘blinded therapists’ items, which is to be expected given the interventions in all trials

involved exercise. Eight used concealed allocation and four used blinded assessors. Seven

demonstrated baseline comparability. Seven obtained at least one key outcome for more than

85% of participants and seven analysed data according to intention-to-treat.

Participants

From 11 randomised controlled trials [16-27] 1197 participants had undergone TKA, 98%

due to osteoarthritis and 2% due to trauma and other pathologies. The mean age of

participants was 69 years, 67% were women and the average body mass index was 30 kg/m2

from available data.

Interventions

The majority of trials were conducted in the acute hospital setting (n=8) and remaining trials

conducted in the inpatient rehabilitation setting (n=3). The most common intervention was

Physiotherapy interventions after total knee arthroplasty Page 8 of 28

accelerated physiotherapy compared with standard physiotherapy in three trials [18, 20, 21].

Similarly another trial [24] examined early hydrotherapy versus late hydrotherapy protocols.

One trial [26] investigated hydrotherapy versus land-based physiotherapy. Three trials [16,

17, 25, 27] investigated the effects of the prescription of an additional exercise (ergometer

cycling, slide-board exercises and eccentric hamstring exercises) to standard physiotherapy.

One trial [22] investigated twice daily physiotherapy versus once daily physiotherapy. Two

trials [19, 23] compared technology-assisted physiotherapy with standard physiotherapy. See

Table 2 for details of the interventions.

Outcomes

The most common outcomes to measure pain and activity included Western Ontario and

McMaster Universities Arthritis Index (WOMAC) (n=6 trials), Bodily Pain and Physical

Function subscales of Short Form 36 Health Survey (SF-36) (n=3 trials), Knee Society Score

(KSS) (n=3 trials) and Visual Analogue Scale (VAS) (n=2 trials). LOS was measured in

seven trials and knee ROM was measured in six trials.

Effect of interventions

Hydrotherapy vs. land-based physiotherapy

A high quality individual trial [26] investigated the effect of two different hydrotherapy

interventions combined with standard physiotherapy versus standard physiotherapy and

additional land-based therapy. Both hydrotherapy groups demonstrated a statistically

significant improvement in activity compared to the standard physiotherapy and additional

land-based physiotherapy group at day 14 post-operatively, however neither demonstrated

any difference for LOS (Table 3). Knee ROM outcomes were not separated from total hip

arthroplasty data and therefore could not be analysed.

Physiotherapy interventions after total knee arthroplasty Page 9 of 28

Accelerated physiotherapy vs. standard physiotherapy

Meta-analysis of three trials with 447 participants provided low quality evidence that

accelerated physiotherapy compared to standard physiotherapy was effective for reducing

acute hospital LOS (MD -3.5 days, 95% CI -5.7 to -1.3) (Figure 2, Table 4). Meta-analysis of

activity was unable to be performed due to differences in reporting methods. One high quality

individual trial [18] demonstrated improved activity at 5-7 days, 6 weeks and 3 months post-

operatively. Another high quality individual trial [20] did not provide sufficient data to

determine the effect on activity. One high quality trial [20] demonstrated a significant

improvement in pain and knee ROM at time of discharge from acute hospital. A high quality

individual trial [24] comparing early commencing hydrotherapy to late commencing

hydrotherapy did not demonstrate any differences for pain or activity from 3 to 24 months

post-operatively (Table 3).

Technology-assisted physiotherapy vs. standard physiotherapy

Meta-analysis of two trials with 196 participants provided very low quality evidence that

technology-assisted physiotherapy compared to standard physiotherapy did not show any

difference for activity approximately one month following TKA (SMD -0.34, 95% CI -0.82 to

0.13) (Figure 3, Table 4). The two individual low quality trials [19, 23] did not report

outcomes of pain. The one trial [19] that reported LOS and knee ROM provided insufficient

data for analysis (Table 3).

Standard physiotherapy and an additional exercise vs. standard physiotherapy

Three trials investigating the effect of specific physiotherapy exercises in addition to standard

physiotherapy [16, 17, 25, 27] versus standard physiotherapy alone could not be combined in

meta-analysis due to heterogeneity. None of these trials, two high quality [17, 25, 27] and one

Physiotherapy interventions after total knee arthroplasty Page 10 of 28

low quality [16], demonstrated any significant difference for measures of pain, activity or

LOS. One high quality individual trial [17, 27] did not demonstrate any significant differences

in knee ROM. A lesser quality individual trial [16] demonstrated an improvement in knee

extension ROM in favour of the standard physiotherapy group day 10 post-operatively,

however no significant differences in knee ROM at day 30 post-operatively (Table 3).

Twice daily physiotherapy vs. once daily physiotherapy

A high quality individual trial [22] of twice daily physiotherapy versus once daily

physiotherapy did not demonstrate any significant difference for measures of pain, activity,

hospital LOS or knee ROM (Table 3).

DISCUSSION

The results of this systematic review demonstrate accelerated physiotherapy regimens, where

the patient is mobilised within 24-hours of surgery, are the most beneficial active

physiotherapy interventions during the acute hospital stay following TKA. Activity and ROM

were significantly improved whilst LOS was reduced by 3.5 days. Physiotherapy regimens

involving the addition of specific exercises did not demonstrate significant improvements in

patient outcomes. Most of the impairment-based trials were conducted more than ten years

ago, whilst the most recently conducted trials are focused towards activity-based interventions

with early mobilisation. This is likely a reflection of the shift in physiotherapy management of

this patient population, where the focus is on achieving functional independence early post-

operatively to facilitate rehabilitation in the home environment. Therefore, our findings

indicate that physiotherapy interventions post-TKA should be focused on activity-based

interventions in the inpatient setting.

Physiotherapy interventions after total knee arthroplasty Page 11 of 28

A defining aspect of physiotherapy management across the three trials [18, 20, 21] that

investigated accelerated physiotherapy was mobilisation within 24 hours of surgery. This is

consistent with the results of a systematic review that demonstrated early mobilisation of

patients following hip and knee arthroplasty reduced acute hospital LOS by 1.8 days [28]. The

findings of our meta-analysis must not be solely attributed to the physiotherapy intervention

alone, as the trials were primarily investigating the effect of an ‘enhanced recovery’ pathway

which entails a multidisciplinary and multimodal approach. Previous literature also attributes

the success of enhanced recovery pathways being due to the process itself rather than the

individual interventions it comprises [29]. Implementation of a pathway requires an organised

and logistical framework, standardised procedures and a multidisciplinary approach to all

aspects of patient care [30]. Consequently, this would necessitate a significant change to

practice for all disciplines involved. Enhanced recovery pathways have been shown to

improve patient satisfaction [31] and cost efficiency as a result of a reduced hospital LOS

[32]. Therefore implementation of an enhanced recovery pathway incorporating an early

mobilisation regimen would be a worthwhile change to practice and investment of resources.

There is limited literature to direct physiotherapists as to which types of exercise are most

beneficial or considered ‘best practice’ following TKA. For this reason current physiotherapy

regimens have been described as being based on traditional practices rather than scientific

evidence [7]. Three studies in this review [16, 17, 25, 27] investigated the effect of an

additional specific exercise to standard physiotherapy. The additional exercises in all three

trials were directed towards addressing impairment, such as joint ROM [17, 25, 27],

proprioception [25] and muscle function [16, 25], however the results did not demonstrate

improvements in knee ROM, pain, activity or LOS. Given that knee ROM one year post-

operatively correlates directly with activity and functional restriction [33], addressing ROM

Physiotherapy interventions after total knee arthroplasty Page 12 of 28

impairment appears to be a necessary component of exercise regimens following TKA.

However further research is required to determine whether this is sufficiently addressed

through functional retraining and early mobilisation regimes, or if specific ROM exercises are

required.

A high quality trial [26] in this review suggests that hydrotherapy combined with land-based

therapy may be more effective in improving activity than land-based therapy alone. This may

be explained by a number of theories, such as reduced joint loading due to buoyancy [34] or

changes to the cardiovascular and autonomic nervous systems [35], resulting in reduced pain

and lower limb oedema. Hydrotherapy has been found to be safe to commence as early as day

four post-orthopaedic surgery, with no increase in wound infection risk provided an

appropriate water-proof dressing is applied [36]. With the mean hospital LOS reported as 5-6

days [5, 6], it would be impractical to implement hydrotherapy in the acute setting. Therefore

patients who are transferred to a rehabilitation facility would be more likely to benefit from

early hydrotherapy. Further high quality research is required to establish if early

commencement of hydrotherapy can reduce LOS in the inpatient rehabilitation setting.

Currently the evidence for technology-assisted physiotherapy interventions in enhancing

patient activity following TKA does not justify its utilisation in the acute hospital and

rehabilitation settings compared to standard physiotherapy [19, 23]. The use of technology in

rehabilitation of people with TKA has also been investigated in the community setting. A

recent randomised controlled trial concluded that the use of Nintendo Wii Fit [37] for balance

retraining was equally effective in improving patient outcomes as standard community-based

physiotherapy interventions. However, to justify the additional expense of technology-

Physiotherapy interventions after total knee arthroplasty Page 13 of 28

assisted physiotherapy interventions it is pivotal that the intervention produces improved

outcomes for patients when compared to standard physiotherapy.

The majority of trials included in this systematic review had a low risk of bias. However there

was a consistent lack of participant and therapist blinding across the trials, therefore

introducing a high risk of performance and detection bias. This has been identified as a

common difficulty when evaluating the effects of non-pharmacological treatments [38].

Additionally, two of the 11 trials contained less than 50 participants, which is a concern

because small sample sizes lead to low statistical power [39] and inflated confidence intervals

around the effect sizes. Due to insufficient reporting only five of the 11 trials [18-21, 23] were

able to be included in meta-analyses, and each meta-analysis contained only two to three

trials. There was also a degree of subjectivity in determining if the trials were sufficiently

homogenous in their interventions to combine in meta-analysis. However decisions were

made with careful clinical consideration and analysis conducted with the more conservative

random effects model. Furthermore, the meta-analyses were rated low in quality, therefore

reducing confidence in these findings.

The most beneficial active physiotherapy intervention in the acute hospital setting following

TKA is accelerated physiotherapy regimens involving early mobilisation, most commonly

delivered as a component of an enhanced recovery pathway. This is a clinically significant

finding, with hospital LOS reduced by an average of 3.5 days.

Physiotherapy interventions after total knee arthroplasty Page 14 of 28

Acknowledgements: Thank you to Nick Taylor for his guidance and contribution to this

systematic review.

Ethical approval: Not applicable.

Funding: Nil.

Conflict of Interest: Nil.

Appendix 1

Medline Search Strategy (n = 252)

Population

S1. (MH “Arthroplasty, Replacement, Knee”) OR “knee arthroplasty” S2. (MH

“Arthroplasty, Replacement, Knee”) OR “knee replacement”

S3 = S1 OR S2

Intervention

S4. “physiotherapy*” S5. (MH “Physical Therapy”) OR “physical therap*” S6. (MH

“Exercise”) OR “exercise*” S7. “mobilis*” S8. “mobiliz*” S9. “ambulat*” S10. (MH

“Walking”) OR “walk*” S11. (MH “Electric Stimulation”) OR “electrical stimulation” S12.

(MH “Hydrotherapy”) OR “hydrotherapy*” S13. (MH “Aquatic Exercises”) OR “aquatic

therap*” S14. (MH “Pilates”) OR “Pilates” S15. “balance training” S16. (MH “Biofeedback”)

OR “biofeedback” S17. (MH “Resistance Training”) OR “resist* training” S18. “strength

training”

S19 = S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14

OR S15 OR S16 OR S17 OR S18

Outcome

Physiotherapy interventions after total knee arthroplasty Page 15 of 28

S20. (MH “Pain”) OR “pain” S21. “function*” S22. (MH “Length of Stay”) OR “length of

stay”

S23 = S20 OR S21 OR S22

Design

S24. (MH “Randomised Controlled Trials”) OR “randomis*” S25. “randomiz*” S26.

“control* trial”

S27 = S24 OR S25 OR S26

S28 = S3 AND S19 AND S23 AND S27

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passive motion or slider board therapy compared with exercise only: a randomized controlled

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[32]. Lovald ST, Ong KL, Malkani AL, Lau EC, Schmier JK, Kurtz SM, et al.

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Physiotherapy interventions after total knee arthroplasty Page 20 of 28

Table 1. PEDro scores of included studies.

Study Random Concealed Groups Participant Therapist Assessor < 15% Intention Between-group Point Total
allocation allocation similar at blinding blinding blinding dropouts -to-treat difference estimate and (0 to 10)
baseline analysis reported variability
reported
Beaupre et al.
(2001) [27] & Davies
Y Y Y N N Y Y Y Y Y 8
et al.
(2003) [17]
Codine et al.
Y N N N N N N N Y Y 3
(2004) [16]
den Hertog et al.
Y Y Y N N N Y Y Y Y 7
(2012)[18]
Eisermann et al.
Y N Y N N N N N Y Y 4
(2004)[19]
Labraca et al.
Y Y N N N Y Y N Y Y 6
(2011) [20]
Larsen et al.
Y Y N N N N Y Y Y Y 6
(2008) [21]
Lenssen et al.
Y Y Y N N Y Y Y Y Y 8
(2006) [22]
Li et al.
Y N N N N N N N Y Y 3
(2014) [23]
Liebs et al.
Y Y Y N N N Y Y Y Y 7
(2010) [25]
Liebs et al.
Y Y Y N N N Y Y Y Y 7
(2012) [24]
Rahmann et al.
Y Y Y N N Y N Y Y Y 7
(2009) [26]
Y = Yes, N = No

Physiotherapy interventions after total knee arthroplasty Page 21 of 28

Table 2. Summary of included studies

Study Participants Setting Intervention Comparison Outcome measures Follow-up

Beaupre et Exp (n = 40), mean Acute Slide-board Ex + standard PT Standard PT Pain = WOMAC (pain), SF- 3mo
al. (2001) age 68 yrs, 50% hospital D2 additional Kn ROM slide-board Exs D1 sit out of bed. D2 commence 36 (BP) 6mo
[27] female, OA = 95%. to Pt’s tolerance. walking. D3 walking in parallel Activity = WOMAC
Con (n = 40), mean Dosage: Minimum of 2 x 10min bars or with gait aid, Kn ROM
(function), SF-36 (PF)
age 69 yrs, 30% sessions in addition to standard PT. slide-board Exs & quads strength
female, OA = 90%. Exs. D4 SLR & stair climbing. Ice ROM = Active Flex/Ext
applied before & after Exs.
Dosage: 30min Ex sessions.
Davies et
al. (2003) LOS = days
[17]
Codine et Exp (n = 30), mean Inpatient Eccentric hamstrings + standard PT Standard PT Activity = KSS (function & D40
al. (2004) age 75 yrs, 53% rehabilitation Submaximal eccentric isokinetic Kn mobilisation (manual + CPM), knee)
[16] female. strength Exs (10 degrees of movement isometric strengthening of Kn ROM = Active Flex/Ext
Con (n = 30), mean per sec). Monitored with dynamometer. muscle groups, proprioceptive
age 71 yrs, 70% Ice applied after Exs. enhancement, walking Exs.
female. Dosage: 15mins 5days/w, for 3w.
den Exp (n = 74), mean Acute Accelerated pathway Standard pathway Activity = WOMAC (total), D5-7
Hertog et age 67 yrs, 69% hospital First mobilisation D0. Stair climbing First mobilisation D2. Exs: AKSS D15-23
al. (2012) female, mean BMI commenced D2. Exs: as per standard walking, passive Flex/Ext, LL LOS = days 6w
[18] 31, OA = 97%. pathway. Use of positive messages muscle strengthening, respiratory
Con (n = 73), mean “yes you can” & comparison of training. 3mo
age 68 yrs, 73% progress to fellow Pts. Type: Daily 1hr individual PT
female, mean BMI Type: Daily 2hr PT sessions, focus on sessions.
30, OA = 99%. ADLs in a living room environment. Discharge planning: occurred
Discharge planning: Pts informed when Pt felt ready, Pts not
discharge scheduled for D6. informed of intended LOS.
Eisermann Exp (n = 68), mean Inpatient Computer-assisted PT + standard PT Standard PT Activity = FIM, HSS, FFbH Discharge
et al. age 70 yrs, 66% rehabilitation Exs (as per standard PT) provided to Pt Exs performed with or without ROM = Flex# 6mo
(2004) [19] female, 22 days via “Training Assistant” device (includes equipment (such as balls or
since surgery. LOS = days
movement descriptions, video rubber bands).30min group PT
Con (n = 68), mean animations & feedback devices - sessions with 8-10 Pts.
age 70 yrs, 79% movement sensors & webcams). Dosage: 3-5days/w for duration of
female, 24 days Dosage: 30min session instructing use inpatient rehab stay (3-4w).
since surgery. of device. Then as per standard PT.

Physiotherapy interventions after total knee arthroplasty Page 22 of 28

 Labraca et Exp (n = 138), mean Acute Early rehabilitation Standard PT Activity = Barthel Index, Discharge
al. (2011) age 66 yrs, 73% hospital Commenced within 24hrs of surgery. Remained at rest in bed or chair Tinetti Balance#
[20] female. D1: Kn ROM 0-40degrees, isometric for first 24hr with no treatment. Pain = VAS
Con (n = 135), mean quads/hams. D2: transfer chair, Commenced 48-72hr post-op.
age 66 yrs, 81% Then as per early rehabilitation. ROM = Flex/Ext
standing & walking, seated ROM,
female. isotonic muscle Ex. D3: progressed gait Dosage: Daily 45 minute LOS = days
aid, walking, ADLs & D2 Exs. D4: sessions.
increased walking distance, strength
Exs, stair climbing & ADL practice.
Dosage: Daily 45min sessions.
Larsen et Exp (n = 15), mean Acute Accelerated pathway Standard pathway LOS = days Discharge
al. (2008) age 68 yrs, 60% hospital Information session 1w pre-op. Admitted day before surgery. D1:
[21] female, OA = 100%. Admitted day of surgery. D0 first Exs in bed, first mobilisation. Days
Con (n = 12), mean mobilisation. D1: 4hr out of bed doing following: Pt in hospital gown,
age 67 yrs, 58% PT & OT training. Days following: 8hrs mobilisation increased to meet
female, OA = 92%. mobilisation per day, Pt wears own discharge criteria, care given in
clothes, work towards set daily goals. response to Pt’s needs.
Lenssen et Exp (n = 21), mean Acute Twice daily PT Once daily PT Pain = WOMAC (pain), VAS D4
al. (2006) age 70 yr, 71% hospital Exs: active/passive Kn mobilisation, Exs: as per twice daily PT group. Activity = WOMAC 6w
[22] female. quads strengthening, functional Exs Dosage: 1 x 20min daily PT (function), KSS (function) 3mo
Con (n = 22), mean (supine to sit to stand transfers, sessions.
age 67 yrs, 77% walking, stair climbing). ROM = Active & Passive
female. Dosage: 2 x 20min daily PT sessions. Flex/Ext
LOS = days
Li et al. Exp (n = 30). Acute Robot-assisted rehab + standard PT Standard PT Activity = HSS, Berg 1w
(2014) [23] Con (n = 30). hospital CPM & NMES as per standard PT. CPM 1hr daily. Peri-knee NMES balance, 6min walking 2w
Early exoskeleton rehab with robotic 30mins 2x daily. Isometric quads distance 1mo
assistance (simulates normal walking in & hams, ankle pumps, bed-aided
a partial weight support condition, standing & walker-aided gait 3mo
speed 45-70m/min). 30mins 2x daily. training 30mins 2x daily. 6mo
Dosage: 5days/w, for 2w. Dosage: 5 days/w, for 2w. 12mo
Liebs et al. Exp (n = 85), mean Inpatient Ergometer cycling + standard PT Standard PT Pain = WOMAC (pain) 3mo
(2010) [25] age 70 yrs, 73% rehabilitation Bicycle ergometer commenced 2w Exs to improve ROM, muscle Activity = WOMAC 6mo
female, mean BMI post-op. Initial session with PT, strength, venous return, balance, (function), SF-36 (PCS), 12mo
30, OA = 98%. minimum resistance to target muscular coordination & gait. Practice of
Lequesne Hip and Knee 2yrs
Con (n = 74), mean coordination, proprioception & ROM ADLs, transfers, walking, stairs &
age 70yrs, 70% (not cardio). uneven surfaces. Score
female, mean BMI Dosage: 3days/w for 3w. Dosage: daily for 3w.
29, OA = 100%.

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 Liebs et al. Exp (n = 87), mean Acute Early aquatic therapy Late aquatic therapy Pain = WOMAC (pain) 3mo
(2012) [24] age 69, 70% female, hospital Aquatic Exs commenced D6. Wound Aquatic therapy Ex commenced Activity = WOMAC 6mo
mean BMI 29, OA = covered with waterproof dressing (Op- D14 (when wound healed). (function), SF-36 (PCS), 12mo
99%. site). Aquatic Exs: proprioception, Lequesne Hip and Knee 2yrs
Con (n = 98), mean Aquatic & land Exs as per late aquatic coordination & strength with floats
age 71, 73% female, Score
therapy group. & kickboards.
mean BMI 29, OA = Dosage: 30mins 3days/w, 5w post-op. Land Exs: ROM, muscle strength,
98%. balance, coordination & gait,
ADLs, transfers, walking, stairs.
Dosage: 30mins 3days/w, 5w
post-op.
Rahmann Exp 1 (n = 18), Acute Aquatic PT (Exp1) + standard Ward PT Additional Ward PT + standard Activity = WOMAC (total), D14
et al. mean age 69 yrs, hospital Fast pace (80-88bpm). Standing at Ward PT 10MWT 6mo
(2009) [26] 44% female, mean xiphisternal level 30% WB (progressed Standard Ward PT: As clinically ROM = Flex#
BMI 28, TKA (n = 8). to waist level 50% WB) walking determined by treating PT for first
Exp 2 (n = 19), forward, back & side, Hip 3days post-op. D4 onwards once LOS = days
mean age 69, 63% Abd/Add/Flex/Ext, squats, heel raises, daily (standard orthopaedic
female, mean BMI lunges on step, step-ups, bilateral arm clinical pathway).
28, TKA (n = 7). swing. On plinth scissors, Hip Ext,
Con (n = 17), mean kicking, cycling. Seated Kn Flex/Ext. Additional ward PT Exs: Transfer,
age 70, 80% female, Dosage: 40min daily D4 until discharge. gait & stairs practice circulation &
mean BMI 29, TKA Water Exercise (Exp2) + standard deep breathing Exs. Bed Exs
(n = 12). Ward PT inner range quads, active Hip &
Slow pace (50-58bpm). Standing at Kn Flex, bridging, SLR. Seated
neck level 10% WB walking forwards, active Kn Flex/Ext. Standing Hip
single leg balance non-operative leg, Abd, Hip/Kn Flex/Ext, mini-squats,
march on spot, hand claps, elbow heel raises, calf stretches, Hams
Flex/Ext. On plinth scissors, cycling, Kn curls.
Flex/Ext. Supine (neck, Hip & Kn floats) Dosage: 40min daily D4 until
lateral trunk Flex, sculling, lumbar spine discharge.
mobilisations.
Dosage: 40min daily D4 until discharge.
Exp = experimental, Con = control, yrs = years, SD = standard deviation, OA = osteoarthritis, PT = physiotherapy or physical therapy, Exs = exercises, D = post-operative day,
Kn = knee, Ext = extension, Flex = flexion, Pt = patient, x = times, post-op = post-operative, ROM = range of motion, Quads = quadriceps, reps = repetitions, SLR = straight leg
raise, LOS = length of stay, WOMAC = Western Ontario and McMaster Universities Arthritis Index, SF-36 = Short Form 36 Health Survey (BP = Bodily Pain, PF = Physical
Function, PCS = Physical Health Composite Score), Hams = hamstrings, mo = months, w = weeks, CPM = continuous passive motion, KSS = Knee Society Score, BMI = body
mass index, ADLs = activities of daily living, LL = lower limb, AKSS = American Knee Society Score, FIM = Functional Independence Measure, HSS = Hospital for Special
Surgery Score, FFbH = Hanover Functional Ability Questionnaire, PF = plantarflexion, DF = dorsiflexion, VAS = Visual Analogue Scale, pre-op = pre-operative, OT =
Occupational Therapy, m = metres, NMES = neuromuscular electrical stimulation, bpm = beats per minute, Abd = Abduction, Add = Adduction, WB = weight bearing, 10MWT =
10 Metre Walk Test.
#
Unable to report post-intervention scores, SMD or MD due to insufficient data provided by authors

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Table 3. Post-intervention scores and SMD (95% CI) between groups for activity and pain or MD (95% CI) between groups for length of stay
and range of motion.

Outcome Study Groups Difference between groups

Hydrotherapy and land-based
Hydrotherapy and land-based physiotherapy minus land-based
physiotherapy Land-based physiotherapy physiotherapy
Activity Rahmann [26] – Aquatic PT 37.1 (6.6) 48.4 (5) -1.91 (-3.02 to -.80)$
Rahmann [26] – Water Exercise 32.4 (7.1) 48.4 (5) -2.62 (-3.94 to -1.30)$
Length of Stay Rahmann [26] – Aquatic PT 7.4 (1.6) 8.3 (1.9) -0.90 (-2.07 to 0.27)
Rahmann [26] – Water Exercise 8.1 (1.7) 8.3 (1.9) -0.20 (-1.38 to 0.98)
Early hydrotherapy Late hydrotherapy Early minus late hydrotherapy
Activity Liebs [24] 21.9 (19.4) 26.8 (20.7) -0.24 (-0.55 to 0.06)
Pain Liebs [24] 20.1 (20) 22.5 (21.7) -0.11 (-0.42 to 0.19)
Accelerated physiotherapy minus
Accelerated physiotherapy Standard physiotherapy standard physiotherapy
Activity den Hertog [18] 1.85 (1.2) 2.35 (1.2) -0.41 (-0.74 to -0.09)$
Pain Labraca [20] 3.01 (2.35) 5.36 (2.5) -0.96 (-1.21 to -0.71)$
ROM – Flexion Labraca [20] 88.11 (2.35) 71.82 (16.81) 16.29 (13.43 to 19.15)$
ROM – Extension Labraca [20] 0.68 (1.84) 2.8 (1.1) -2.12 (-2.48 to -1.76)$
Twice daily minus once daily
Twice daily physiotherapy Once daily physiotherapy physiotherapy
Activity Lenssen [22] 73.4 (14.9) 78 (11.3) -0.34 (-0.95 to 0.26)
Length of stay Lenssen [22] 4.1 (0.9) 4.5 (1.3) -0.40 (-1.07 to 0.27)
Pain Lenssen [22] 15.2 (3) 16.2 (2.4) -0.36 (-0.97 to 0.24)
ROM – Flexion Lenssen [22] 103.7 (13) 105.1 (15) -1.40 (-9.78 to 6.98)
ROM – Extension Lenssen [22] 5.3 (5.1) 8.3 (5.5) -3.00 (-6.17 to 0.17)
Additional specific exercise and
Additional specific exercise and standard physiotherapy minus
standard physiotherapy Standard physiotherapy standard physiotherapy
Activity Beaupre [27] 72 (17) 72 (17) 0.00 (-0.48 to 0.48)
Codine [16] 70.71 (16.85) 66.92 (15.26) 0.23 (-0.28 to 0.74)
Liebs [25] 25.4 (17.7) 24.9 (16.9) 0.03 (-0.31 to 0.37)
Length of stay Davies [17] 7.2 (2.6) 7.5 (3) -0.30 (-1.53 to 0.93)
Pain Beaupre [27] 75 (19) 73 (18) 0.11 (-0.38 to 0.59)
Liebs [25] 22.4 (17.7) 23.8 (20.5) -0.07 (-0.41 to 0.27)
ROM – Flexion Beaupre [27] 96 (14) 91 (11) 5.00 (-1.44 to 11.44)
Codine [16] 102.32 (7.75) 104.64 (7.8) -2.32 (-6.25 to 1.61)
ROM – Extension Beaupre [27] 4 (3) 3 (6) 1.00 (-1.36 to 3.36)
Codine [16] 2.67 (3.72) 1.25 (2.2) 1.42 (-0.13 to 2.97)

Physiotherapy interventions after total knee arthroplasty Page 25 of 28

$
Significant difference between intervention and control groups

Table 4. Summary of meta-analyses.

Intervention No. of trials No. of participants Outcome Timeframe SMD (95% CI), I2 MD (95% CI), I2 Quality of
evidence
(GRADE)
Accelerated 3[18, 20, 21] 447 No. of days (length Discharge -3.47 [-5.67, - Low*
Physiotherapy of hospital stay) 1.27], 75%
Technology- 2[19, 23] 196 Hospital for 1 month post- -0.34 [-0.82, 0.13], Very Low**
assisted Special Surgery operatively 58%
Physiotherapy score
GRADE = GRADE working group grades of evidence (see reasons for downgrade)
*Reasons for downgrade: Statistical heterogeneity (I2 = 75%), large confidence interval (>.8).
**Reasons for downgrade: All trials rated lesser quality (PEDro < 6), statistical heterogeneity (I2 = 58%), indirectness of results (different types of technology), large
confidence interval (>.8).

Physiotherapy interventions after total knee arthroplasty Page 26 of 28

 Titles and abstracts screened
(n = 1019)

Papers excluded after application of

eligibility criteria to titles/abstracts
(n = 978)

Potentially-relevant papers retrieved

for evaluation of full text (n = 41)

Papers excluded after application of

eligibility criteria to full text (n =29)

 Research design not RCT (n = 4)

 Community/Outpatient setting (n =
6)
 Passive intervention (n = 6)
 <85% of participants underwent
TKA due to OA (n = 2)
 TKA and THA data not separated
(n = 3)
 Did not include outcomes of pain,
activity or length of stay (n = 2)
 Unable to access full text (n = 1)
 Trial not published e.g.
conference, poster (n = 3)
 Non-English language (n = 1)
 Insufficient information regarding
intervention (n = 1)

For remaining 12 trials hand-

searching the reference list and
citation tracking applied (n = 0)

Papers included in review (n = 12)

(11 RCTs)

Figure 1. Flow of studies through the review.

Physiotherapy interventions after total knee arthroplasty Page 27 of 28

Physiotherapy interventions after total knee arthroplasty Page 28 of 28