Professional Documents
Culture Documents
Guidelines
Physical Therapist Management of D.U. Jette, PT, DPT, DSc, FAPTA, MGH,
Institute of Health Professions, Boston,
Massachusetts.
S.J. Hunter, PT, DPT, OCS,
Total Knee Arthroplasty Rehabilitation Services, Intermountain
Healthcare, 36 South State Street, Salt
Lake City, UT 84111 (USA). Address all
Diane U. Jette, Stephen J. Hunter, Lynn Burkett, Bud Langham, David S. correspondence to Dr Hunter at:
stephen.hunter@imail.org.
Logerstedt, Nicolas S. Piuzzi, Noreen M. Poirier, Linda J.L. Radach, Jennifer E.
L. Burkett, MBA, BSN, RN, ONC,
Ritter, David A. Scalzitti, Jennifer E. Stevens-Lapsley, James Tompkins, Joseph National Association of Orthopaedic
Zeni Jr, for the American Physical Therapy Association Nurses (NAON), Wyomissing,
Pennsylvania.
B. Langham, PT, MBA, Home Health
and Hospice Services, Encompass
A clinical practice guideline on total knee arthroplasty was developed by an American Health, Birmingham, Alabama.
Physical Therapy (APTA) volunteer guideline development group that consisted of physical
T
his clinical practice guideline (CPG) is based on a health, well-being, and quality of life. Typically, the
systematic review of published studies with regard physical therapist is a graduate of a physical therapist
to the physical therapist management of patients education program accredited by the Commission on
undergoing total knee arthroplasty. In addition to Accreditation in Physical Therapy Education and is
providing practice recommendations, this guideline also licensed to practice physical therapy. Orthopedic
highlights limitations in the literature, areas that require surgeons, adult primary care clinicians, geriatricians,
future research, intentional vagueness, and quality hospital-based adult medicine specialists, physiatrists,
improvement activities. occupational therapists, nurse practitioners, physician
assistants, emergency clinicians, and other health care
This guideline is intended to be used by all qualified and professionals who routinely see this type of patient in
appropriately trained physical therapists involved in the various practice settings may also benefit from this
management of patients undergoing total knee guideline. This guideline is not intended for use as a
Future Research
Consideration for future research is provided for each
recommendation within this document.
Methods
The methods used to create this CPG were intended to
minimize bias and enhance transparency in the selection,
appraisal, and analysis of the available evidence. These
processes are vital to the development of reliable,
transparent, and accurate clinical recommendations for
management of patients undergoing TKA.6 Methods from
the APTA Clinical Practice Guideline Process Manual 6
Table 1.
Summary of Recommendations for Total Knee Arthroplasty (TKA)
Prognostic factors: body mass ♦ Physical therapist management should take into consideration the following factors when
index (BMI), depression, determining prognosis, providing treatment, and engaging in informed decision making and
preoperative ROM, physical expectation setting with patients undergoing TKA:
function and strength, age, Higher BMI is associated with more postoperative complications and worse postoperative outcomes.
diabetes, number of
comorbidities, and sex Depression is associated with worse postoperative outcomes.
Preoperative ROM is positively associated with postoperative ROM but has minimal, if any, effect on
physical function and quality of life.
(Continued)
Table 1.
Continued
the highest-quality evidence, outcomes based on the next Voting on the Recommendations
level of quality were considered until at least 2 or more GDG members agreed upon the strength of every
occurrences of an outcome had been acquired. For recommendation. When changes were made to the
example, if there were 2 “moderate”-quality occurrences strength of a recommendation based on the magnitude of
of an outcome that addressed a recommendation, the benefit or potential risk, harm, or cost, the GDG voted in
recommendation does not include “low”-quality person, via phone, or email and provided an explanation
occurrences of evidence for this outcome. A summary of in the rationale.
excluded articles can be viewed in Supplementary
Appendix 1, and the data findings for each Role of the Funding Source
recommendation can be viewed in Supplementary The American Physical Therapy Association, which
Appendix 3. funded the volunteer GDG, provided coordination and
played no role in the design, conduct, and reporting of the
recommendations.
Literature Searches
The medical librarian conducted a comprehensive search
Peer Review and Public Commentary
of MEDLINE, Embase, and the Cochrane Central Register
Following the formation of a final draft, the CPG review
of Controlled Trials based on key terms and concepts
draft was subjected to a 4-week peer review for additional
from the PICO(T) questions. Retrospective
input from external content experts and stakeholders.
noncomparative case series, medical records review,
More than 350 comments (Supplementary Appendix 4)
meeting abstracts, meta-analyses, systematic reviews,
were collected via an electronic structured review form.
historical articles, editorials, letters, and commentaries
All peer reviewers were required to disclose any potential
were excluded. Bibliographies of relevant systematic
conflicts of interest, which were recorded and, as
reviews were hand searched for additional references. All
necessary, addressed.
databases were last searched on July 13, 2018, and
searches were limited to publication dates from 1995 to
2018 and publications in the English language. After modifying the draft in response to peer review, the
CPG was subjected to a 2-week public comment period.
Commenters consisted of members of the APTA Board of
Defining the Strength of the Recommendations Directors (Board), the APTA Scientific and Practice Affairs
Judging the strength of evidence is only a steppingstone Committee (SPAC), all relevant APTA sections, stakeholder
toward arriving at the strength of a CPG recommendation. organizations, and the physical therapy community at
The operational definitions for the quality of evidence are large. More than 194 public comments were received.
listed in Table 2, and rating of magnitude of benefits Revisions to the draft were made in response to relevant
versus risk, harms, and cost is provided in Table 3. The comments.
strength of recommendation, listed in Table 4, takes into
account the quality, quantity, and trade-off among the
benefits and harms of a treatment, the magnitude of a Recommendations
treatment’s effect, and whether there are data on critical
outcomes. Table 5 addresses how to link the assigned Preoperative Exercise Program ♦
grade with the level of obligation of each Physical therapists should design preoperative exercise
recommendation. programs and teach patients undergoing total knee
Table 2.
Rating Quality of Evidence
Table 3.
Magnitude of Benefit, Risk, Harm, and Cost
Rating of
Definition
Magnitude
Substantial The balance of the benefits versus risk, harms, or cost overwhelmingly supports a specified direction.
Moderate The balance of the benefits versus risk, harms, or cost supports a specified direction.
Slight The balance of the benefits versus risk, harms, or cost demonstrates a small support in a specified direction.
Table 4.
Strength of Recommendations
Table 5.
Linking Strength of Recommendation, Quality of Evidence, Rating of Magnitude, and Preponderance of Risk Versus Harm
to the Language of Obligation
Level of Obligation to
Recommendation Quality of Evidence and Rating Preponderance of Benefit or
Follow
Strength of Magnitude Risk, Harm, or Cost
the Recommendation
arthroplasty (TKA) to implement strengthening and 3 months postsurgery with preoperative training.9
flexibility exercises. Evidence Quality: High; • Modified WOMAC, subscales including function and
Recommendation Strength: Moderate. stiffness, and pain using the visual analog scale
(VAS) improved at 1 and 3 months postsurgery with
preoperative quadriceps muscle exercise.16
Action Statement Profile • SF-36 physical function component score improved
Aggregate evidence quality: 6 high-quality studies9– 14 and at 12 weeks postsurgery with preoperative lower
3 moderate-quality studies.15– 17 extremity exercise.14
• Knee Injury Osteoarthritis Outcomes Survey
Rationale. Four high-quality studies9,11,13, 14 and 2 (KOOS) activities of daily living (ADL) improved at
moderate-quality studies15,16 support the use of 6 weeks and 3 months postsurgery with
preoperative physical therapy training/exercise programs preoperative physical therapy.15
for patients undergoing TKA and are associated with • KOOS ADL, KOOS pain score, and EuroQol Five
better postoperative functional outcomes. Summary of the Dimensions Questionnaire and visual analog scale
outcomes measured and length of follow-up: (EQ5D –VAS) (generic health status instrument)
improved at 6 weeks postsurgery with preoperative
• Total Western Ontario and McMaster Universities neuromuscular exercise program and standard
Osteoarthritis Index (WOMAC), subscales including education.17
function, pain and stiffness, and the Medical • Iowa Level of Assistance Scale total score improved
Outcomes Study 36-Item Short Form Survey (SF-36) at 3 days postsurgery with preoperative physical
physical function scores improved at 1 and therapy.11
information given, the more satisfied patients were with Exclusions. None were identified.
their care; however, they suggested that preoperative
education did not completely fulfill patients’ expectations
Quality improvement. Organizations may use the
and that postoperative education was also important.
completion of a preoperative visit to physical therapy that
includes education as a performance indicator.
Soeters et al20 implemented preoperative physical therapy
education for patients with total joint arthroplasty (hip
and knee) that included a one-time, one-on-one Implementation and audit. Organizations may audit the
educational session with a physical therapist and gave rate of occurrence of preoperative physical therapy visits
patients access to a microsite providing additional that include education for patients who have undergone
information about postoperative complications, TKA and its association with postoperative complication,
precautions, and mobility. They found that patients length of stay, and patient satisfaction.
Potential benefits, risks, and harms of implementing Rationale. Four high-quality studies,22– 25 6
this recommendation. Benefits are as follows: moderate-quality studies,26–31 and 2 low-quality studies32 ,33
• Improved patient adherence examined the effect of CPM use. Findings from 1
• Decreased postsurgical complication moderate-quality study31 and 2 low-quality studies32,33
• Shortened inpatient length of stay reported some significant statistical effects; however, these
findings were contradicted by nonsignificant statistical
findings in higher-quality studies.22–25 The outcomes
Risk, harm, and/or cost are as follows: measured included knee flexion and extension ROM as
well as need for manipulation under anesthesia.
• No expected risk or harms were associated with this
Additionally, meta-analyses for the outcomes of function
recommendation. (standardized mean difference [SMD] = 0.14 [−1.10 to
• There may be an expected associated expense for
0.39])23,24,28 and hospital length of stay (weighted mean
the visit. difference [WMD] = −0.15 [−0.60 to 0.30])24,28,29 showed
nonsignificant results.
Benefit-harm assessment. There is a preponderance of
benefit for this recommendation. Potential benefits, risks, and harms of implementing
this recommendation. Benefits are as follows:
Future research. Additional research on patient
preoperative education led by a physical therapist or other • Results for outcomes in function were
team member is required. This research should evaluate nonsignificant.
the method and frequency of the education delivered. In • Results for hospital length of stay were
addition, outcomes such as patient anxiety, health literacy, nonsignificant.
and satisfaction should be considered when evaluating the
benefits of preoperative education. Risk, harm, and/or cost are as follows:
Value judgments. Although there was not a • Bed rest may be prolonged with CPM use.
preponderance of high-quality evidence, the GDG felt • There is an inconvenience of use.
compelled to make a recommendation to support the use • Although costs were not reported in studies, there is
of preoperative education for patients undergoing TKA. an expected associated expense.
Preoperative education was believed to be associated with
better postoperative functional outcomes. Benefit-harm assessment: There is a preponderance of
evidence to support that there is increased risk, harm,
Intentional vagueness. Not applicable. and/or cost related to use of CPM for uncomplicated TKA.
Future research. Some subpopulations may benefit from from 2 high-quality studies34 ,39 and 2 moderate-quality
CPM, and this could be explored with studies large studies40 ,43 found no increased complications between
enough to allow subgroup analyses or by narrowing cryotherapy modalities. A meta-analysis of 3 studies36 ,38 ,43
inclusion criteria. Examples may be those with TKA evaluated cryotherapy devices versus standard cold packs
revisions or those with particularly poor preoperative for pain management and found no statistically significant
ROM. difference.
Value judgments. None were identified. Potential benefits, risks, and harms of implementing
this recommendation. Benefits are as follows:
Intentional vagueness. The nature of an uncomplicated
• Improvement in pain management.
TKA is not explicit in most studies. Only 1 study implied a
• Low cost and relatively easy application in all
definition of uncomplicated by exclusions of patients with
Implementation and audit. Organizations may audit Potential benefits, risks, and harms of implementing
occurrence of documentation of use of cryotherapy after this recommendation. Benefits are as follows:
TKA to assist in the management of pain.
• Improved gait function, walking distance, balance,
physical function, and health-related quality of life.
• Improved activities and participation (eg, mobility,
Physical Activity ♦♦♦ self-care, domestic life).
It is the consensus of the work group that physical
therapists should develop an early mobility plan and teach
patients who have undergone TKA regarding the Risk, harm, and/or cost are as follows:
importance of early mobility and appropriate progression
• No expected risk or harms are expected when
of physical activity, based on safety, functional tolerance,
and physiological response. Evidence Quality: progression is monitored and prescribed
differences in knee flexion ROM at 6 weeks’ follow-up. Benefit-harm assessment: There is benefit in reducing
Extension ROM was not measured. blood loss and swelling in the first 7 days postsurgery.
Improved flexion ROM is not long term, with only 1 study
One high-quality study69 found decreased blood loss and showing improvement after 6 weeks and none after
knee circumference at 7 days after surgery in a group of 6 months. The impact on extension ROM is not known.
patients with the knee positioned in 45 degrees of hip Most of these studies had a length of stay greater than
flexion and 90 degrees of knee flexion when compared 7 days or the length of stay was unreported. There is a
with a second group with the knee positioned in full question about the generalizability of the results of these
extension. These positions were maintained for the first studies to postoperative care due to the length of stay. For
6 hours postoperatively. There were no statistical these reasons, the strength of this recommendation is weak.
differences in knee flexion ROM at 7 days between
groups. Extension ROM was not measured. Future research. Continued comparative studies that
also exceeded historical controls in ROM and function and specific parameter for resistance and intensity; however,
may not have provided a true low-intensity comparison. Molla et al79 found that 6 weeks of progressive resistance
training 3 times per week starting the day after surgery
Effectiveness of high-intensity resistance training may be resulted in better balance outcomes on the Sharpened
limited by arthrogenic muscular inhibition of the Romberg, Star Excursion, and Berg Balance Scale tests.
quadriceps (muscle activation deficits) in the early Husby et al80 found that resistance training 3 times per
postoperative period.78 Patients with large muscle week for 8 weeks initiated 8 days after TKA resulted in
activation deficits may not experience sufficient muscle better muscle strength and that gains persisted through
overload with resistance training to achieve comparable 12 months after TKA.
strength gains as those of patients without muscle
activation deficits.
Exclusions. None were identified.
and quality of life.100 One high-quality study Prognostic Factors: Tobacco Use and
reported a higher total complication rate with Patient Support ♦♦♦
greater degree of comorbidity.102 It is the consensus of the work group that active tobacco
(i) Sex: Five high-quality62 ,64 ,81 –83 and 11 use and lack of patient support (eg, environmental factors
moderate-quality86 ,88 –90,92,95,96,98–100,104 studies were including, but not limited to, support and relationships)
included. Male and female sex may or may not be should be considered as prognostic/risk factors associated
related either positively or negatively to recovery with less than optimal functional outcomes. Evidence
after TKA, depending on the outcome measures Quality: Insufficient; Recommendation Strength: Best
studied; therefore, a general statement of the impact Practice.
of sex on recovery cannot be made. Three
high-quality studies62 ,64 ,81 and 8 moderate-quality
Action Statement Profile
studies86 ,88 ,89 ,92 ,95 ,96 ,99 ,104 reported no effect of sex on a
Aggregate evidence quality is as follows: There were no
Implementation and audit. Organizations may audit Intentional vagueness. Not applicable.
occurrence of risk factors with a patient prior to patient
undergoing a TKA. Exclusions. None were identified.
Quality improvement. Organizations may use impairments and functional limitations that are
documentation of prognostic factors with patient before commonplace after surgery.
TKA as a performance indicator.
Future research. Existing studies on this topic varied
widely in their scope and methodology. Although there
Implementation and audit. Organizations may audit
was limited evidence supporting supervised versus
occurrence of prognostic factors prior to patients
unsupervised physical therapy programs, there is a dearth
undergoing TKA.
of literature on this topic, perhaps due to ethical issues
related to withholding supervised physical therapy after
Postoperative Physical Therapy surgery. Studies that compare supervised physical therapy
Supervision ♦ with a true nonactive control or home exercise program
Supervised physical therapist management should be are warranted. Future work should include (1)
Benefit-harm assessment: There is a preponderance of Rationale. There is limited evidence to support the
benefit that supervised physical therapist management benefit of individualized physical therapist management
should be provided after TKA to address physical over group-based sessions. One high-quality,107 2
moderate-quality,108,109 and 1 low-quality110 studies Value judgments. Limitations in the existing research
reported individualized therapy was neither superior nor reduced the ability to draw a conclusion about the
inferior to group rehabilitation. Various patient functional superiority of either treatment approach, and the decision
outcomes improved over the course of the studies, to use either treatment may be based on a variety of
regardless of participation in individual or group physical institutional-, therapist-, and patient-related factors.
therapy sessions.
Intentional vagueness. The lack of a clear, high-quality,
The evidence was limited given differences in study comparative study that included dose-equivalent group
populations, the timing of the programs postsurgery and and individual-based treatment plans precluded a
differences in doses of the intervention between and preferential recommendation for either approach.
within groups. In the only high-quality study,107 8-week
group-based physical therapy was compared with usual Exclusions. None were identified.
recommendations matched actual discharge setting, there impact on patient safety in postoperative discharge to
was a lower probability of hospital readmissions than home, on pain levels, and on return to function.
when they did not match. Similarly, Falvey et al120
identified the contributions of physical therapists to the Related to future research in the area of postoperative
discharge planning team when preparing for care setting (or location), no high-quality studies were
transitions and the potential to mitigate readmissions. Two evaluated on this topic. There is a lack of studies
studies have shown a measure of function, using a evaluating measures or standard processes for objective
standardized tool administered on the first therapy visit, to discharge decision making. The current Medicare joint
have predictive value in discharge disposition from acute replacement bundle includes all costs incurred up to
settings.121,122 These findings suggest benefits of the 90 days postsurgery. Studies evaluating the outcome and
inclusion of physical therapy with interdisciplinary cost of the timing and setting of postacute care will
discharge planning early in the hospitalization. Jette et become more and more important. Studies are needed
Future research. From the current research regarding Outcomes Assessment ♦♦♦
care navigator/discharge planner and social support, the It is the consensus of the work group that physical
work group was left with far more questions than therapists should collect data from the Knee Injury
answers. It is unclear whether the care Osteoarthritis Outcomes Survey Joint Replacement (KOOS
navigator/discharge planner was present from the JR) as a patient-reported outcome measure and from both
beginning of the decision process. Similarly unclear is the 30-Second Sit-to-Stand and TUG tests as
whether the care navigator went home with the patient performance-based outcomes to demonstrate the
and assisted in personal care, safety, and home physical effectiveness of care provided. At a minimum, these
therapy. The interventions provided by the care navigator measures should be collected at the first visit and upon
regarding home safety assessment, developing a personal conclusion of care from each setting. Evidence Quality:
home care plan, securing assistive devices, and supporting Insufficient; Recommendation Strength: Best Practice.
pain management strategies were not indicated by the
researchers. Likewise, the study of social support was Action Statement Profile
narrowly focused on contact from provider to patient Aggregate evidence quality: No PICO(T) questions were
related to function. More research using a broader created to specifically look at outcomes assessment, and,
application of different types of social support from as such, the search returned no studies addressing this
within patients’ larger communities is needed to assess the topic.
Rationale. The GDG discussed the psychometric Value judgments. Expert opinion supports the use of
properties, clinical utility, and importance to the patient of identified outcome assessments. In addition, there are
multiple tests and measures that have been used when value-based incentive payment programs (eg,
describing outcomes for patients undergoing TKA. The Comprehensive Care for Joint Replacement Model) and
group was in consensus with this recommendation. There regulatory mandate’s for Joint Commission Advanced
is evidence for the reliability and validity of the use of the Certification that require the use of KOOS JR assessment
tools in TKA.123– 127 Lyman et al124 found that internal tool. There is need for consistency of outcomes to
consistency for the KOOS JR was high and that correlation improve understanding of the effectiveness of care
with other validated knee surveys was excellent. provided for patients undergoing TKA.
Responsiveness was high, and floor and ceiling effects
were reasonable. Alghadir et al123,126,127 reported excellent Intentional vagueness. Not applicable.
interrater and intrarater reliability for the TUG test, and
17 Villadsen A, Overgaard S, Holsgaard-Larsen A, Christensen 35 Radkowski CA, Pietrobon R, Vail TP, Nunley JA 2nd, Jain
R, Roos EM. Postoperative effects of neuromuscular exercise NB, Easley ME. Cryotherapy temperature differences after
prior to hip or knee arthroplasty: a randomised controlled total knee arthroplasty: a prospective randomized trial.
trial. Ann Rheum Dis. 2014;73:1130–1137. J Surg Orthop Adv. 2007;16:67–72.
18 Huang SW, Chen PH, Chou YH. Effects of a preoperative 36 Ruffilli A, Castagnini F, Traina F, et al.
simplified home rehabilitation education program on length Temperature-controlled continuous cold flow device after
of stay of total knee arthroplasty patients. Orthopaedics & total knee arthroplasty: a randomized controlled trial study.
Traumatology: surgery & Research. 2012;98:259–264. J Knee Surg. 2017;30:675–681.
19 Ingadottir B, Johansson Stark A, Leino-Kilpi H, 37 Rui W, Long G, Li G, Yang Y, Hengjin L, Zhenhu W. Effects
Sigurdardottir AK, Valkeapaa K, Unosson M. The fulfilment of ethyl chloride spray on early recovery after total knee
of knowledge expectations during the perioperative period arthroplasty: a prospective study. J Orthop Sci. 2017;22:
of patients undergoing knee arthroplasty–a Nordic 89–93.
perspective. J Clin Nurs. 2014;23:2896–2908. 38 Schinsky MF, McCune C, Bonomi J. Multifaceted comparison
20 Soeters R, White PB, Murray-Weir M, Koltsov JCB, Alexiades of two cryotherapy devices used after total knee
MM, Ranawat AS. Preoperative physical therapy education arthroplasty: cryotherapy device comparison. Orthop Nurs.
53 Arnold JB, Mackintosh S, Olds TS, Jones S, Thewlis D. following total knee arthroplasty: a randomized study. Int J
Improvements in knee biomechanics during walking are Surg. 2015;23(Pt A):82–86.
associated with increased physical activity after total knee 71 De Fine M, Traina F, Giavaresi G, et al. Effect of different
arthroplasty. J Orthop Res. 2015;33:1818–1825. postoperative flexion regimes on the outcomes of total knee
54 Taniguchi M, Sawano S, Kugo M, Maegawa S, Kawasaki T, arthroplasty: randomized controlled trial. Knee Surg Sports
Ichihashi N. Physical activity promotes gait improvement in Traumatol Arthrosc. 2017;25:2972–2977.
patients with total knee arthroplasty. J Arthroplasty. 2016;31: 72 Jiang C, Lou J, Qian W, Ye C, Zhu S. Impact of flexion versus
984–988. extension of knee position on outcomes after total knee
55 Piva SR, Farrokhi S, Almeida G, Fitzgerald GK, Levison TJ, arthroplasty: a meta-analysis. Arch Orthop Trauma Surg.
DiGioia AM. Dose-associated changes in gait parameters in 2017;137:257–265.
response to exercise programs after total knee arthroplasty: 73 Avramidis K, Karachalios T, Popotonasios K, Sacorafas D,
secondary analysis of two randomized studies. Int J Phys Papathanasiades AA, Malizos KN. Does electric stimulation
Med Rehabil. 2015;3:3–7. of the vastus medialis muscle influence rehabilitation after
56 Bruun-Olsen V, Heiberg KE, Wahl AK, Mengshoel AM. The total knee replacement? Orthopedics. 2011;34:175.
immediate and long-term effects of a walking-skill program 74 Avramidis K, Strike PW, Taylor PN, Swain ID. Effectiveness
obese patients: a prospective matched study with follow-up 105 Hudakova Z, Zieba HR, Lizis P, et al. Evaluation of the
of 5-10 years. J Arthroplasty. 2014;29:1192–1196. effects of a physiotherapy program on quality of life in
88 Rossi MD, Eberle T, Roche M, et al. Use of a squatting females after unilateral total knee arthroplasty: a prospective
movement as a clinical marker of function after total study. J Phys Ther Sci. 2016;28:1412–1417.
knee arthroplasty. Am J Phys Med Rehabil. 2013;92: 106 Akbaba YA, Yeldan I, Guney N, Ozdincler AR. Intensive
53–60. supervision of rehabilitation programme improves balance
89 Sharma L, Sinacore J, Daugherty C, et al. Prognostic factors and functionality in the short term after bilateral total knee
for functional outcome of total knee replacement: a arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2016;
prospective study. J Gerontol A Biol Sci Med Sci. 1996;51: 24:26–33.
M152–M157. 107 Fransen M, Nairn L, Bridgett L, et al. Post-acute rehabilitation
90 Si HB, Zeng Y, Zhong J, et al. The effect of primary total after total knee replacement: a multicenter randomized
knee arthroplasty on the incidence of falls and clinical trial comparing long-term outcomes. Arthritis Care
balance-related functions in patients with osteoarthritis. Sci Res (Hoboken). 2017;69:192–200.
Rep. 2017;7:16583. 108 Artz N, Dixon S, Wylde V, et al. Comparison of group-based
91 Stevens-Lapsley JE, Petterson SC, Mizner RL, Snyder-Mackler outpatient physiotherapy with usual care after total knee
121 Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, 125 Peer MA, Lane J. The knee injury and osteoarthritis outcome
Jette AM. AM-PAC "6-clicks" functional assessment scores score (KOOS): a review of its psychometric properties in
predict acute care hospital discharge destination. Phys Ther. people undergoing total knee arthroplasty. J Orthop Sports
2014;94:1252–1261. Phys Ther. 2013;43:20–28.
122 Menendez ME, Schumacher CS, Ring D, Freiberg AA, Rubash 126 Unver B, Kalkan S, Yuksel E, Kahraman T, Karatosun V.
HE, Kwon Y-M. Does “6-clicks” day 1 postoperative mobility Reliability of the 50-foot walk test and 30-sec chair stand test
score predict discharge disposition after total hip and knee in total knee arthroplasty. Acta Ortop Bras. 2015;23:184–187.
arthroplasties? The Journal of Arthroplasty. 2016;31: 127 Yuksel E, Kalkan S, Cekmece S, Unver B, Karatosun V.
1916–1920. Assessing minimal detectable changes and test-retest
123 Alghadir A, Anwer S, Brismee JM. The reliability and reliability of the timed up and go test and the 2-minute walk
minimal detectable change of timed up and go test in test in patients with total knee arthroplasty. J Arthroplasty.
individuals with grade 1-3 knee osteoarthritis. BMC 2017;32:426–430.
Musculoskelet Disord. 2015;16:174. 128 Poitras S, Wood KS, Savard J, Dervin GF, Beaulé PE.
124 Lyman S, Lee YY, Franklin PD, Li W, Cross MB, Padgett DE. Assessing functional recovery shortly after knee or hip
Validation of the KOOS, JR: a short-form knee arthroplasty arthroplasty: a comparison of the clinimetric properties of