Physical Therapy Management of Total Knee Arthroplasty (TKA)

Reference : Jette DU, Hunter SJ, Burkett L, et al. Physical Therapist Management of Total Knee
Arthroplasty. Phys Ther. Aug 31 2020;100(9):1603-1631. doi:10.1093/ptj/pzaa099

Abstract: A clinical practice guideline on total knee arthroplasty was developed by an American
Physical Therapy (APTA) volunteer guideline development group that consisted of physical
therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on
systematic reviews of current scientific and clinical information and accepted approaches to
management of total knee arthroplasty.

Summary of Recommendations:

Intervention Practice Recommendations

- PT should design + teach preoperative exercise programs including
strengthening + flexibility exercises
- Potential Benefits:
Preoperative  ↑: Activities, balance, knee ROM, isometric knee + hip
Exercise Program strength, report of quality of life (QOL)
 ↓: Pain, length of inpatient stay
- Future research needs to address specific regimen, type, frequency,
duration, and progression
- PT + team should provide patients with preoperative education
including expectations during hospital stay, factors influencing d/c
planning, post-op rehab program, safe transferring techniques, use
of AD, fall prevention
Preoperative - Insufficient evidence but best practice
Education - Potential Benefits:
 ↑: Patient adherence
 ↓: Postsurgical complication + length of inpatient stay
- Future research needs to address method + frequency of education
delivered
- PT should not use CPM for patient’s undergoing TKA
- Results for functional outcomes and hospital length of stay were
Continuous Passive insignificant
Movement Device - Potential Risks:
(CPM)  ↑: Prolonged bed rest, inconvenient, cost
- Future research needs to address potential benefits of CPM use in
subpopulations
- PT should teach + encourage use of cryotherapy for early post-op
pain management
- Potential Benefits:
 ↑: Pain management; low cost + easy to apply
Cryotherapy
- Potential Risks:
 ↑: Skin irritation, burns, and frostbite—not expected when
utilized properly
- Future research should address frequency + duration of use
 - PT should develop an early mobility plan and teach pt’s the
importance of early mobility and appropriate progression of
physical activity
- Insufficient evidence but best practice
Physical Activity - Potential Benefits:
 ↑: Gait function, walking distance, balance, physical
function, activities and participation, + health related QOL
- Future Research needs to address recommendations for physical
activity type, frequency, duration, + progression
- PT should teach pt’s PROM, AAROM, AROM exercises for surgical
knee
- Insufficient evidence, but best practice
- Potential Benefits:
Postoperative ROM
 ↑: Knee ROM, functional outcomes
 ↓: Postsurgical complication
- Future research not anticipated as unlikely to have approval for a
true control group with no ROM exercises
- PT may teach pt’s to position surgical knee in flexion (30-90°)
during rest
- Potential Benefits:
 ↑: Short term knee flexion
Immediate  ↓: Blood loss associated with TKA surgery, swelling in first
Postoperative 7 days post-op
Flexion During Rest - Potential Risks:
 ↑: Risk of developing limited extension ROM
- Future research should compare/contrast positioning of knee
during early post-op period with larger population sizes; and
outcomes related to knee extension ROM
- PT should design, implement, teach, progress pt’s in high-intensity
strength training and exercise programs within 7 days post-op
- Potential Benefits:
 ↑: Muscle strength, all activities related to mobility,
Resistance + balance, knee extension ROM
Intensity of Exercise - Potential Risks:
 ↑: Pain + swelling with too aggressive progression
- Future research should address optimal timing of resistance
training and impact of muscle activation deficits on effectiveness of
early progressive resistance training
- PT should provide supervised management with setting
determined by pt safety, mobility, environmental + personal factors
- Potential Benefits:
Postoperative
 ↑: Supervised PT may produce better outcomes + allow for
Physical Therapy
more appropriate + safe exercise progression compared to
Supervision unsupervised PT
- Future research should compare supervised PT with a true control
HEP
Physical Therapy - PT management should be initiated within 24 hrs of surgery + prior
 to d/c.
Postoperative - Potential Benefits:
Timing  ↑: Physical function
 ↓: Pain, length of inpatient stay
- PT should provide guidance to interdisciplinary team + patient in
terms of safe d/c disposition, pt functional status, assistive
equipment, + services necessary to support safe d/c from acute
Physical Therapy care.
Discharge Planning - Potential Benefits:
 ↑: likelihood of most appropriate d/c disposition,
preparation of pt for safe and independent d/c home, pt
functional performance
- PT should collect data from the Knee Injury Osteoarthritis
Outcomes Survey Joint Replacement ( KOOS JR), 30-sec sit to stand
+ TUG to demonstrate effectiveness of treatment
- Measures should be collected at first visit and conclusion of care
from each setting
- Potential Benefits:
Outcomes  ↑: Standardization of communication across care
Assessment continuum, documentation of objective results of
implementing plan of care
 ↓: Minimal time to administer assessment
- Potential Risks:
 ↑: Time required to perform outcome measures
- Future Research should continue to identify suitable outcome
measures, including assessment of validity + reliability