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ISSN: 0959-3985 (print), 1532-5040 (electronic)

Physiother Theory Pract, 2014; 30(4): 287–297

! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2013.868064

CASE REPORT

A daily adjustable progressive resistance exercise protocol and

functional training to increase quadriceps muscle strength and
functional performance in an elderly homebound patient following
a total knee arthroplasty
Gunay Ardali, PT, MS, DPT
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Visiting Nurse Service of New York, New York, NY, USA

Abstract Keywords
Background and purpose: There is no routinely prescribed protocol to address quadriceps DAPRE, functional training, home care,
weakness and functional impairments following a total knee arthroplasty (TKA). The purpose of total knee arthroplasty
this case report is to introduce and describe the early use of a daily adjustable progressive
resistance exercise (DAPRE) protocol as an adjunct to standard rehabilitation to maximize History
quadriceps muscle strength and functional performance in an elderly homebound patient
following a TKA. Case description: A 61-year-old female was referred to home care physical Received 14 October 2012
therapy for 6 weeks following left TKA due to functional deficits and inability to activate the Revised 3 September 2013
weak left quadriceps muscle. In phase I, the patient received three visits with emphasis on Accepted 21 September 2013
edema management, improving left knee range of motion, and reducing pain. Phase II Published online 7 January 2014
consisted of two main components: (1) a DAPRE protocol aimed at maximizing the quadriceps
For personal use only.

strength and (2) functional training aimed at improving normal gait patterns, transfers, and
dynamic balance. Outcomes: The patient made substantial improvements in both quadriceps
muscle strength and functional performance in the first seven weeks following the TKA. The
patient had a pain free return to daily living activities. Discussion: The results suggest that early
initiation of a DAPRE protocol was free of adverse events and improved quadriceps strength
and functional performance for this patient.

Introduction some insight into the cause of the force weakness observed prior
to and following TKA. Cross-sectional data indicated that after
Total knee arthroplasty (TKA) is a common surgical procedure
age 50, muscle mass decreases at an annual rate of 1–2%. The
designed to alleviate knee pain and improve function in individ-
decline in muscle strength is higher, amounting to 1.5% per year
uals with knee osteoarthritis (OA) or rheumatoid arthritis. In the
between ages 50 and 60 and 3% per year thereafter. On average, it
USA, nearly 687 000 (Bade and Stevens-Lapsley, 2011) TKAs are
is estimated that 5–13% of elderly people aged 60–70 years are
performed each year for severe knee OA and this number is
affected by age-associated skeletal muscle atrophy, and the
expected to nearly double by 2020 (Bade and Stevens-Lapsley,
numbers increase to 11–50% for those aged 80 years or above
2011; Meier et al, 2008). Most patients who undergo TKA
are between the ages of 50 and 80 years. Despite the high
(von Haehling, Morley, and Anker, 2010; Tseng, Marsh,
14
20
Hamilton, and Booth, 1995). The muscle atrophy is generally
incidence of knee replacement and the availability of post-
manifested by preferential type II myofiber atrophy, myofiber
operative rehabilitative approaches, the secondary muscle
necrosis, and myofiber type grouping, and increased intra-
impairments are not well defined and are an understudied area
muscular content of non-muscle tissues (Hunter, McCarthy, and
of post-operative care. Of particular interest to rehabilitation
Bamman, 2004). Fast contracting, fatigable type II fibers are
professionals is the acute profound post-operative deficit in
significantly smaller in muscles from aged men and women, while
quadriceps muscle strength that fails to resolve completely even
the size of slow contracting, fatigue-resistant type I fibers remain
years after surgery (Meier et al, 2008). Quadriceps weakness
almost unaffected with increasing age (Lexell, 2000).
has been correlated with slower walking speeds, longer stair-
Quadriceps weakness is a hallmark impairment of an osteo-
climbing times and increased risk of falls (Chandler, Duncan,
arthritic knee (Mizner, Petterson, and Snyder-Mackler, 2005).
Kochersberger, and Studenski, 1998). The reasons for quadriceps
Individuals with knee OA, prior to undergoing a TKA, on average
weakness are not well understood in this patient population;
have a 20% quadriceps deficit (Slemenda et al, 1997). It has been
however, the examination of morphological alterations of aged
suggested that a combination of muscle atrophy and neuromus-
human quadriceps muscles with and without injury can provide
cular activation deficits contribute to residual quadriceps strength
impairments (Meier et al, 2008). Surgical procedures used in TKA
Address correspondence to Gunay Ardali, PT, MS, DPT, Visiting Nurse involve trauma to the extensor mechanism, and preoperative
Service of New York, 1250 Broadway #7, New York, NY 10001, USA. quadriceps weakness is dramatically compounded in early post-
E-mail: gardali03@hotmail.com operative phases (Mizner, Petterson, and Snyder-Mackler, 2005).
 288 G. Ardali
A 60% reduction in quadriceps strength and 17% decrease in
cross-sectional area are evident one month after surgery.
Functional performance is reported to worsen by 20–25% one
month after TKA. Most patients recover to preoperative status;
however, impairments in quadriceps strength remain below
healthy age-matched peers for years after TKA (Mizner,
Petterson, and Snyder-Mackler, 2005; Petterson et al, 2009).
Walsh, Woodhouse, Thomas, and Finch (1998) report one year
after TKA, marked physical impairments and functional limita-
tions persist as compared with individuals with no diagnosed
knee disease. Walking speeds for men with TKA were 13% and
17% slower at normal and fast speeds, respectively. Their stair-
climbing ability was even more compromised (51% slower).
Walking speeds for women with TKA were 17% and 18% slower
at normal and fast speeds, respectively. Similarly, their stair-
climbing time was more compromised (43% slower). Men with
TKA were 37–39% weaker and performed 36–37% less total work
of their knee extensors compared with the control subjects.
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Similarly, women with TKA had knee extensor strength deficits of
28–29% and performed 24% less total work. At one year,
quadriceps deficit was 40% despite rehabilitation programs
(Walsh, Woodhouse, Thomas, and Finch, 1998).
A National Institutes of Health–sponsored consensus develop-
ment conference on TKA concluded that there is no evidence
supporting the generalized use of any specific preoperative or
post-operative rehabilitation interventions (Petterson et al, 2009).
Physical therapy interventions after TKA differ from physical
therapist to physical therapist and surgeon to surgeon. They range
from no treatment at all to structure and progressive rehabilitation
that includes strengthening, manual therapy, and modalities.
For personal use only.
Strength training programs have been used to counter
morphological changes in muscles attributable to injury, aging,
or surgery (Perhonen et al, 1992; Roth, Ferrell, and Hurley, 2000).
Patients with TKA are able to increase their quadriceps muscle
strength and functional performance with a progressive volitional
strength training program 2–3 times a week for 6 weeks (Petterson
et al, 2009). Furthermore, there is preliminary evidence that a
progressive high-intensity rehabilitation program can lead to
improved outcomes in this population, though this program was
initiated one month after surgery, when strength and functional
deficits were already profound (Bade and Stevens-Lapsley, 2011;
Petterson et al, 2009). There are concerns in the orthopedic
community that a higher intensity intervention initiated immedi-
ately following hospital discharge could lead to increased pain
and swelling and ultimately to poorer range of motion (ROM) and
functional outcomes. The results of Bade and Stevens-Lapsley
(2011) study indicated that utilization of a high-intensity program
initiated early in the course of recovery after TKA led to superior
strength and functional outcomes as compared with those of a
lower intensity rehabilitation program in an age- and sex-matched
control group, without leading to increased pain or decreased
knee ROM outcomes, in this small group of patients.
A daily adjustable progressive resistance exercise (DAPRE)
protocol is a structured progressive strengthening technique
developed clinically by Knight (1990) in an effort to provide an
objective means of increasing resistance concurrently with
strength increases during knee rehabilitation subsequent to
injury or surgery (Knight, 1990). The DAPRE system is a
5-RM to 7-RM (repetition maximum) with a 4-set system. The
DAPRE allows patients to exercise to their fullest potential while
simultaneously accounting for daily variations in their strength
levels (Wilson, 2008). The DAPRE technique is based on the
concept of systematic progression such as periodized strength
training regimen where training variables (rest, overall training
volume, sets per workout, repetitions per set, and intensity of
training) are manipulated over a period of time in order to
Physiother Theory Pract, 2014; 30(4): 287–297
optimize adaptations to resistance training (Lorenz, Reiman,
and Walker, 2010; Mann, Thyfault, Ivey, and Sayers, 2010).
Wawrzyniak, Tracy, Catizone, and Storrow (1996) studied the
effect of a 6-week leg press training program in 30 non-athletic
collegiate females on quadriceps femoris peak torque and lower
extremity functional performance. Subjects were trained three
days a week for six weeks using the DAPRE technique.
The DAPRE technique involved performing four sets of
repetitions. During the first set of the DAPRE technique,
half of the maximum weight was performed 10 times. For the
second set, 6 repetitions were performed at 75% of the
maximum weight. In the third set, the maximum weight was
lifted until fatigue. The number of repetitions performed
during the third set determined the amount of weight added or
removed for the next set. The weight was reduced 5 to 10
pounds (lbs) if a participant could lift the weight only a few
times. The weight stayed the same if a participant performed 5
to 7 repetitions. If a participant performed more than 8
repetitions, the fourth set would include an increase of 5 to 10
lbs. The fourth set was performed with maximum effort as
well. The number of repetitions performed during the fourth
set determined the amount of weight added or removed
(working weight) for the next session.
The study concluded that the participants showed significant
increase in quadriceps femoris concentric and eccentric peak
torque from pre-test to post-test (Wawrzyniak, Tracy, Catizone,
and Storrow, 1996).
A modified DAPRE protocol was used by Mann, Thyfault,
Ivey, and Sayers (2010), to compare six weeks of autoregulatory
progressive resistance exercise (APRE) and linear periodization
(LP) for improving strength in division I College football players.
The APRE training used in this study varied slightly from the
DAPRE, but the rationale was similar. Like DAPRE, the goal of
APRE was to work toward a RM. The study’s findings indicated
that the APRE demonstrated greater improvement compared with
LP in 1-RM bench press strength, estimated 1-RM squat strength,
and the number of repetitions performed at a weight of 225 lbs
over the six-week training period in competitive athletes (Mann,
Thyfault, Ivey, and Sayers, 2010). Furthermore, a progressive
resistive exercise program targeting the quadriceps and functional
impairments has not been systematically studied in a home care
environment, and there is no routinely prescribed protocol to
address these deficits following a TKA.
The purpose of this case report is to introduce and describe the
early use of a DAPRE protocol as an adjunct to functional training
to maximize quadriceps muscle strength and functional perform-
ance in an elderly homebound patient following a TKA.
Case description
The patient was a 61-year-old white female. She was a self-
directed and retired customer service representative referred to
home care following left TKA. The patient resided in a private
house, with a very supportive retired spouse, in an urban area.
Previously, the patient was independent in all the activities of
daily living (ADLs), and she had participated in recreational
activities such as gardening and jogging with some degree of left
knee discomfort. She had a left knee partial meniscectomy of the
medial and the lateral menisci four years prior to the TKA. She
reported a resultant improvement in pain and function in her left
knee. However, in the past year, her left knee pain had increased
to a point where she could no longer perform the ADL’s
comfortably. She consulted an orthopedic surgeon, who recom-
mended a TKA. The TKA was performed to alleviate the patient’s
 DOI: 10.3109/09593985.2013.868064
left knee pain from the OA and to improve functional tasks.
Following the TKA, the patient received four days of in-patient
physical therapy, including passive range of motion (PROM)
exercises on the continuous passive motion (CPM) machine,
transfer training, and gait training with a rolling walker. Upon
discharge from the in-patient rehabilitation facility, the surgeon
referred her to home care physical therapy for six weeks due to
functional deficits, lack of left knee active range of motion
(AROM) and inability to activate the weak left quadriceps
muscle, which led her to be homebound.
The patient’s past medical history included Hepatitis C
diagnosed six years ago and a heart murmur that did not interfere
with her home physical therapy and functional performance tests.
She took Celebrex for the knee pain associated with the left knee
OA. She was also taking a daily regimen of glucosamine and
chondroitin sulfate. The patient did not report any significant
medical history for the pulmonary, endocrine, gastrointestinal and
genitourinary systems. For pain management, the patient was
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taking Percocet (oxycodone/acetaminophen) 5 mg/325 mg every
4 h or as needed. Daily anticoagulant (Levenox 40 mg/0.4 ml)
injections were prescribed for two weeks post-op, and afterwards
the patient was instructed to take an oral blood thinner (Aspirin
81 mg) daily to prevent blood clots.
The patient’s stated goals for home care physical therapy were
to improve left knee mobility, to decrease her left knee surgical
pain, to strengthen her left knee muscles, to walk outdoors, and to
climb stairs pain free without assistive devices in order for her to
go to an outpatient physical therapy facility where she could
continue her rehabilitation process.
For personal use only.
Physical therapy examination
The physical therapist performed the initial evaluation, including
an environmental and safety assessment in the patient’s home
approximately one week after the surgery. Vital signs (tempera-
ture, blood pressure, pulse, and respiration) were normal. The
patient’s anthropometric measurements (weight, height, and knee
girth) were obtained. Knee girth was significantly larger on the
left versus the right (51.8 and 47.5 cm, respectively). Knee girth
was determined by measurement of the transverse plane circum-
ference of the knee at mid-patellar height in a supine position
using a flexible plastic measuring tape.
The left knee had a closed incision site with staples in place.
At that time, the patient rated her resting pain as 6 on a pain rating
scale (0–10) and 8 while ambulating with a rolling walker. The
knee pain often awakened her at night. The patient was not able to
ascend and descend stairs at the time of initial assessment, but she
was able to slowly walk on level surfaces with a rolling walker
requiring the supervision of one. She required close supervision to
stand from a chair with the use of her arms, and she could not
perform tub transfers due to very limited left knee flexion. The
patient was unable to lift her left leg up on the bed from a sitting
position. Her left lower extremity was edematous as compared
with the uninvolved leg.
A detailed functional performance and musculoskeletal assess-
ments were performed. See Table 3 for results of these pre-
intervention assessments.
Functional performance measures
Functional independence measure
The functional independence measure (FIM) is the most widely
used instrument to measure outcomes in medical rehabilitation
units and hospitals in the USA. The tool is designed to measure
‘‘burden of care’’, or ‘‘the type and amount of assistance required
for a person with a disability to perform basic life activities’’.
A daily adjustable progressive resistance exercise 289
FIM scores range from 1 to 7 on an ordinal scale, with 1 indicating
dependence and 7 indicating independence. The FIM consists of
23 items in 7 areas of function: (1) self-care (6 items);
(2) sphincter control (2 items); (3) mobility (3 items); (4) loco-
motion (3 items); (5) communication (2 items); (6) social
adjustment/cooperation (4 items); and (7) cognition/problem
solving (3 items) (Cournan, 2011; Ottenbacher, Hsu, Granger,
and Fiedler, 1996). The FIM is recognized as the rehabilitation
industry’s most reliable [kappa coefficient for the total FIM was
0.91 (95% CI, 0.82–1.0)], valid, and responsive functional
assessment tool. The ability of the instrument to detect meaning-
ful change in the level of function during rehabilitation has been
observed to be high (Cournan, 2011). The FIM demonstrated
acceptable reliability across a wide variety of settings, raters, and
patients (Ottenbacher, Hsu, Granger, and Fielder, 1996). The
instrument itself does not completely reflect a patients’ true
functional abilities (e.g. distance walked), and therefore the author
used other functional tests in addition to FIM scores.
Timed up-and-go test
The timed up-and-go (TUG) is a test of balance that is commonly
used to examine functional mobility in community-dwelling older
adults. The test requires a patient to stand up, walk 3 m (10 ft),
turn, walk back, and sit down. The time taken to complete the test
is strongly correlated with the level of functional mobility. Older
adults who are able to complete the task in less than 20 s have
been shown to be independent in transfer tasks involved in the
ADLs, and walk at gait speeds that should be sufficient for
community mobility (0.5 m/s). In contrast, older adults requiring
30 s or longer to complete the task tend to be more dependent
in ADLs, and require assistive devices for ambulation. The TUG
was found to be a sensitive (sensitivity ¼ 87%) and specific
(specificity ¼ 87%) measure for identifying elderly individuals
who are prone to falls (Shumway-Cook, Brauer, and Woollacott,
2000). The TUG test was reliable and valid to assess group
change of inpatients on an orthopedic rehabilitation ward (Yeung,
Wessel, Stratford, and MacDermid, 2008). Intra-tester and inter-
tester reliability was 0.95 [95% CI (0.72–0.98)] and 0.98 [95%
CI (0.94–0.99)], respectively, in patients with knee OA (Piva et al,
2004). The minimum detectable change was 1.5 and 1.2 s,
respectively (Piva et al, 2004). Additionally, the TUG test is a
valid and responsive outcome measure for older persons
participating in geriatric rehabilitation (Brooks, Davis, and
Naglie, 2006). One practice test was performed, and the average
of the two subsequent trials was recorded. A stopwatch was used
to measure the time to complete the TUG within the nearest one-
hundredth of a second.
Stair-climbing test
The stair-climbing test (SCT) measures the total time to ascend
and descend 12 standard steps. The patient was asked to complete
the test as quickly as possible, safely, and comfortably; the patient
used the right-sided handrail for stair negotiation. Time to
negotiate the stairs was measured to the nearest one-hundredth of
a second with a stopwatch. The SCT measures a higher level of
function than the TUG test, and therefore reduces the possibility
of a ceiling effect. The SCT is a clinically relevant measure of leg
power impairments (Bean et al, 2007). The reliability coefficient
for this test was reported as 0.90 [95% CI (0.79–0.96)] and the
minimally detectable change associated with the 90% confidence
interval (CI) (MDC90) for this measure has been estimated to be
between 2.6 and 5.5 s in patients recovering from TKA, depend-
ing on the time point assessed (Bade and Stevens-Lapsley, 2011;
Steffen, Hacker, and Mollinger, 2002). One practice test was
performed, followed by one recorded trial.
 290 G. Ardali
Six-minute walk test
The six-minute walk (6-MW) is used to measure the maximum
distance that a person can walk in 6 min on level ground. It is a
sub-maximal test of aerobic capacity, and it appears to be a better
measure of exercise endurance because of its ease of administra-
tion and similarity to normal daily activities (Steffen, Hacker, and
Mollinger, 2002). The reliability coefficient for this test was
reported as 0.94 [95% CI (0.88–0.98)] and the minimally
detectable change associated with the 90% CI (MDC90) for this
measure has been estimated to be 61.34 m in patients the first
1.5 months after TKA (Bade and Stevens-Lapsley, 2011; Kennedy
et al, 2005). The 6-MW test has been favored as a performance
measure because of its strong responsiveness to change over time
in patients with TKA (Mizner et al, 2011). The use of assistive
devices was permitted. The patient used a rolling walker to
complete the test at the initial measurement point (post-op two
weeks) but she walked 6 min without an assistive device at the last
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physical therapy visit.
Single-leg stance test
The single-leg stance (SLS) test measures the length of time the
patient balanced on the involved leg while keeping her hands on her
hips. The test was stopped if: (1) the swing leg touched the floor;
and (2) the tested foot displaced on the floor. The SLS performance
is age-specific and not related to gender. Inter-rater reliability for
the test was determined to be excellent with an intra-class
correlation coefficient of 0.994 [95% CI 0.989–0.996)] for eyes
open and 0.998 [95% CI 0.996–0.999)] for eyes closed (Springer
et al, 2007). The normative reference values for SLS with the eyes
For personal use only.
opened for the 60–69 group age was 27.0 s (Bohannon, 2006). One
practice test was performed with eyes opened, and the average of
the two subsequent trials was recorded. A stopwatch was used to
measure the time within the nearest one-hundredth of a second.
The functional performance measures assessed cover import-
ant domains of lower-extremity physical function such as walking
ability, dynamic and static balance, muscle strength and power,
and movement control. These assessments have been shown to be
reliable and responsive to interventions and to have the ability to
discriminate from low to high functional ability in individuals of
various ages and functional levels (Piva et al, 2004).
Musculoskeletal assessments
Active and passive knee flexion and extension ROM
The knee ROM was measured with a standard long-arm
goniometer. The goniometer axis was placed at the lateral
femoral condyle, the proximal arm was positioned along the
longitudinal axis of the femur, pointed toward the greater
trochanter and the distal arm was aligned with the long axis of
the tibia, pointed toward the lateral malleolus. To determine
flexion ROM, the patient was positioned in supine and asked to
actively slide the heel toward the buttocks. The angle of maximal
active knee flexion was measured. Goniometric measurements of
the knee joint are both reliable and valid with an inter-tester
reliability (r ¼ 0.98; Intraclass Correlation Coefficient
(ICC) ¼ 0.99) and validity (r ¼ 0.97–0.98; ICC ¼ 0.98–0.99)
(Gogia, Brattz, Rose, and Norton, 1987). Changes in knee joint
ROM of more than 6.6 following TKA represent a real clinical
improvement (Jakobsen et al, 2010).
Manual muscle test
Knee extension strength was measured using manual muscle test
(MMT). The MMT employed by physical therapists has been
shown to be a clinically useful tool for measuring muscle strength.
Physiother Theory Pract, 2014; 30(4): 287–297
The knee manual quadriceps strength testing is a valid test when
employed with elderly patients in a home care setting. The
sensitivity and the specificity for manual testing were found to be
90.9% and 78.9%, respectively (Bohannon, 1998). A manual knee
extension muscle test was highly correlated to dynamometer
measures (r ¼ 0.768) (Bohannon, 2001). The inter-examiner
reliability for rectus femoris manual muscle test (MMT) had
a 90.5% agreement between examiners (Pollard et al, 2011).
Six repetition maximum
Although dynamometry testing is considered the ‘‘gold standard’’
for the assessment of muscle strength in vivo, 1-RM testing is
more commonly applied. The 1-RM test is regarded as a popular
test for assessing muscular strength, and the value is defined as
the capacity of a defined muscle or muscle group to exert force
against a resistance in a single maximum effort (Eston and Evans,
2009). One-RM knee extension strength was reported to correlate
strongly with dynamometer results (r ¼ 0.88). One-RM testing
represents a valid means to assess leg muscle strength in vivo in
young and elderly men and women (Verdijk, van Loon, Meijer,
and Savelberg, 2009). Despite its universal application, the safety
of a 1-RM protocol has been questioned as individuals new to
maximal load-bearing activity may incur high muscular, bone,
and ligament stress with the risk of serious muscular injury. The
direct assessment of a 1-RM has also been referred to as time
consuming and impractical for large groups. Such limitations led
the treating physical therapist to employ the sub-maximal load of
6-RM of quadriceps strength, which was also the working weight
in the DAPRE protocol, in order to minimize the limitations and
risks of maximal strength assessment (Eston and Evans, 2009).
Dohoney et al. (2002) reported that 4–6-RM had a higher
predictive accuracy with a corresponding correlation coefficient
of 0.82 as compared with a more commonly used 7–10-RM
testing range. The physical therapist determined the anticipated 6-
RM of the involved leg in seated knee extension, supine terminal
knee extension, and supine straight leg raised extension.
Knee girth measurement
The circumference of the left knee was measured at the mid-
patella region at each session to examine whether engagement in
the protocol had any beneficial or negative effect on swelling. The
circumference was measured with a tape measure with the knee in
full extension. Knee joint circumference measurements are
generally reliable (ICC40.8) within and between physical
therapists. Changes in knee joint circumference of more than
1.0 cm following TKA represent a real clinical improvement
(Jakobsen et al, 2010).
Self-report questionnaires
Knee Outcome Survey–Activities of Daily Living Scale
The Knee Outcome Survey–Activities of Daily Living Scale
(KOS-ADLS) is a 14-item questionnaire with items designated
to assess how patients perceive commonly described knee
symptoms restrict their daily life (pain, stiffness, swelling,
giving way, weakness and limping) as well as their perception
of the level of functional limitations during ADLs (walking up
stairs, down stairs, standing, kneeling, squatting, sitting and
kneeling) (Mizner et al, 2011). Each item is scored 0–5 with
5 indicating ‘‘no difficulty’’ and 0 representing ‘‘unable to
perform’’. Scores are presented as a percentage of the maximal
score, with 100% representing full perceived knee function for
ADLs. The KOS-ADLS questionnaire has an excellent reliability
(ICC ¼ 0.88–0.95), validity (0.70–0.85), and good responsiveness
(0.8–1.1) to treatment for patients with disorders of the knee
 DOI: 10.3109/09593985.2013.868064
(Mizner et al, 2011; Piva, Gil, Moore, and Fitzgerald, 2009). The
minimum clinically important difference (MCID) was 7.1
percentile points (Piva, Gil, Moore, and Fitzgerald, 2009).
Short Form-36 Health Survey
The Short Form-36 Health Survey (SF-36) is a reliable, internally
consistent, and easy-to-administer questionnaire that has been
repeatedly used as a generic health measure in patients with TKA
and knee OA. This questionnaire includes 8 scales of differing
domains of health: (1) physical functioning; (2) bodily pain;
(3) role-physical; (4) general health; (5) vitality; (6) role-
emotional; (7) social functioning and (8) mental health. Each
scale is scored on a 0–100 scale with a 100 representing the best
score possible. The SF-36 has been shown to capture improve-
ments in 7 of its 8 domains in patients after TKA in the first
12 weeks after surgery (Arslanian and Bond, 1999). The MCID
for SF-36 was at least 10 points for patients following TKR
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(Escobar et al, 2007).
Numerical Pain Rating Scale
The patient rated her level of perceived pain intensity at each visit
on a numerical scale from 0 to 10, with 0 representing no pain and
10 representing the worst pain possible. The Numerical Pain
Rating Scale (NPRS) was noted to be valid, reliable (ICC ¼ 0.97
[95% CI ¼ 0.96–0.98], responsive and appropriate for clinical use
(Bijur, Silver, and Gallagher, 2001).
The functional performance measures, musculoskeletal assess-
ments, and self-report questionnaires were completed at three
time points: (1) at the initial home physical therapy visit (one
For personal use only.
week after TKA); (2) right after the removal of the surgical
staples and prior to the initiation of the DAPRE protocol (two
weeks after TKA) and (3) at the last home physical therapy visit.
The patient participated in functional testing on all three
occasions, except that she was not able to perform the stairs
climbing test, 6-MW test, and single leg stance test at the initial
physical therapy assessment.
Physical therapy diagnosis and prognosis
The patient had very limited left knee flexion and left leg
weakness at the initial assessment that appeared to limit her
abilities to carry out functional activities such as ascending and
descending stairs, tub transfers that required her to stand on the
involved leg, and long distance walking. The treating physical
therapist hypothesized that the swelling, pain, and diminished
activity following surgery had caused the patient to lose
completely her left knee ROM. The physical therapist also
hypothesized that the patient’s quadriceps weakness was another
important factor in her inability to perform functional activities
successfully. Based on the clinical findings, the patient’s needs
and beliefs, having a very supportive spouse, and her motivation
to do exercises as well as the desire to return to a high level of
functioning as quickly as possible, the physical therapist
concluded that the patient’s prognosis for achieving her goals
was excellent. The therapist also concluded that she was a good
candidate for a carefully monitored but aggressive rehabilitation
protocol.
Intervention
The clinical findings and patient evaluation led the physical
therapist to recommend the use of a daily adjustable progressive
resistive exercise (DAPRE) protocol to strengthen the quadriceps
muscle so she could have a higher level of functional perform-
ance. A mutual agreement was reached to implement the DAPRE
protocol as a home exercise program after the removal of the
A daily adjustable progressive resistance exercise 291
surgical staples at post-op 14 days for 5 weeks in conjunction
with functional training to increase quadriceps muscle strength
and functional performance. The use of the DAPRE protocol to
increase muscle strength and functional performance in the
athletic population has resulted in greater quadriceps femoris
strength and lower extremity functional performance gains as
compared with traditional strengthening programs. Therefore, the
therapist believed that the DAPRE protocol had the potential to
improve quadriceps strength and functional performance, and it
might be an important component of the rehabilitation program
for this patient.
Phase I
Phase I intervention began at post-op 7 days following TKA and
lasted until the removal of the staples at post-op 14 days. The
patient received three home physical therapy visits in the first
week. The emphasis of intervention in this phase was on edema
management, improving knee flexion and extension ROM,
starting a strengthening program, reducing pain and inflamma-
tion, and improving functional mobility. Therefore, an early initial
one week program of active-assisted, active ROM exercises, and
CPM exercises combined with edema management, and cold pack
application was implemented to address the ROM and functional
deficits before the removal of the surgical staples. Details of the
interventions are provided in Appendix A. The patient was able to
perform all of the interventions without professional supervision
and achieved the necessary left knee ROM and quadriceps muscle
strength to start the next phase interventions.
Phase II
Phase II began after the surgical staples were removed at post-op
2 weeks and when the patient satisfied the following criteria as
described in the literature: (1) 80 of knee flexion; (2) full knee
extension limitation less than 15 ; (3) involved quadriceps
strength greater than 3/5 based on the MMT in seated position
and (4) involved quadriceps isometric muscular endurance of
3 sets of 10 repetitions (Knight, 1990). This phase lasted until the
discharge of the patient to an outpatient physical therapy clinic
eight weeks after surgery. The patient received an average of
45 min for each of the 3 home physical therapy visits per week for
3 weeks and afterward twice a week for the last 2 weeks (total of
13 visits). The intervention protocol consisted of two main
components: (1) the DAPRE protocol aimed at maximizing the
quadriceps strength and (2) functional training aimed at improv-
ing normal gait patterns and dynamic balance. The functional
training consisted of gait training on even and uneven surfaces,
stairs training using a rail and a cane, surface-to-surface transfer
training, and standing dynamic balance training.
The physical therapist introduced and instructed the patient on
the DAPRE protocol with adjustable ankle weights to address the
quadriceps strength and functional deficits. In addition, the patient
was engaged in hamstring and calf muscles stretching exercises.
The patient performed the DAPRE home exercise program that
included three extension exercises to address the quadriceps
deficits: (1) seated knee extensions; (2) supine terminal knee
extensions and (3) supine straight leg raises (Appendix B). She
was instructed to document daily the working weight of 6-RM in a
data booklet for the following five weeks to ensure consistency of
care and patient compliance with the protocol. The patient was
also instructed to continue the DAPRE home exercise program at
least two months after discharge from home physical therapy in
order to achieve age-matched normative levels of functioning.
The DAPRE training protocol consisted of four sets. Sets 1 and
2 were warm-up sets, and sets 3 and 4 were the sets of maximum
effort. Each session was designed around a ‘‘working weight’’,
 292 G. Ardali Physiother Theory Pract, 2014; 30(4): 287–297

which was the weight used during the third set of exercise
(Table 1). During set 1, the patient performed 10 repetitions at
50% of the anticipated 6-RM. During set 2, the patient performed
6 repetitions at 75% of the anticipated 6-RM. Finally, during set 3,
the patient performed as many repetitions as she could at 100% of
the anticipated 6-RM until she could not complete another
repetition. Maximum effort was given during this set. The number
of repetitions performed during the third set determined the
amount of weight to be used during the fourth set (Table 2). The
patient then performed the fourth set with maximum effort.
The number of repetitions performed during the fourth set was
used to calculate the ‘‘working weight’’ for the next session
(Table 2). The original working weights were reduced from 5 to
1 lb, 10 to 2 lbs and 15 to 3 lbs to address the needs of this patient.
The patient did not report any discomfort, increase in the knee
swelling, decrease in the knee ROM, or any major adverse events
during and following the protocol. The only complaint was an
immediate quadriceps muscle fatigue which resolved in a minute.
Physiother Theory Pract Downloaded from informahealthcare.com by McMaster University on 03/31/15
a 31-s improvement on the TUG test. She showed a 5-s
improvement on the left single leg stands and a 15-s improvement
on the SCT, as compared with the initial scores. She also walked
306 ft (94 m) farther on the 6MW test at seven weeks after surgery
and completed the test without an assistive device as compared
with two weeks after surgery.
At visit 16, the patient’s left knee active ROM was 0–108 , and
her passive ROM was 0–112 . Quadriceps muscle strength of the
involved lower extremity, as assessed by the MMT in seated
position, improved from the initial value of 2/5 to 4/5 at 4 weeks
after surgery, and 4/5 at 7 weeks after TKA. Two weeks after
surgery and at the initiation of the DAPRE protocol the patient’s
anticipated 6-RM quadriceps muscle strength of the involved
lower extremity in a sitting position was 1.5 pounds (lbs) which
improved further at 3 weeks and 5 weeks after the protocol to
13 and 18 lbs, respectively (Table 4 and Figure 1). Changes of the
left knee circumferences, as measured through the mid-patellar
level, at discharge revealed a reduction of 2.6 cm as compared

with the initial girth measurement. At discharge from home care,

Outcomes her self-reported scores exceeded her preoperative evaluations
and were substantially greater than her initial scores. By the time
The patient was able to achieve her stated home physical therapy
of discharge from home care physical therapy, the patient
goals to: improve left knee mobility; decrease left knee surgical
had improved by 65% on the KOS ADLs, as compared with her
pain; strengthen left knee muscles; walk outdoors and climb
initial score. The results of the KOS are reported in Figure 2. At
stairs pain free without assistive devices. She was discharged
7 weeks, the patient also demonstrated improvements over
from home health care to an outpatient physical therapy clinic
preoperative values on the SF-36 by 6%. The patient had a pain
following her 16th treatment visit (seven weeks after surgery).
free return to her daily living activities and continued with
The testing results of the outcome measures are reported in
outpatient physical therapy.
Table 3. At the initial physical therapy examination one week
after TKA, the patient was considerably impaired in all functional
Discussion
For personal use only.

performance tests, clinical tests, and self-report questionnaires. At

the end of the patient’s 16th treatment sessions (6 weeks of home This case report provides the results of early application of the
physical therapy and 7 weeks after surgery), she was able to DAPRE protocol to strengthen the quadriceps muscle, in addition
ascend and descend a standard staircase foot over foot without to functional training after a unilateral TKA in a homebound
support and without complaints of pain. She was able to walk elderly patient who presented with significant impairments in
indoors without an assistive device and occasionally required a
standard cane for outdoors ambulation. Her performance-based
scores at discharge were substantially better than her initial Table 3. Outcome measures results.
scores. At discharge, her total FIM score improved by 34 points as
compared with the initial assessment. The patient demonstrated Initial home Initiation of Last
physical the DAPRE home
therapy protocol physical
Table 1. DAPRE protocol for 6-RM. visit post-op: post-op: therapy
1 week 2 weeks visit
Sets Repetitions Intensity % of 6-RM
Functional tests
1 10 50% FIM scores 116 132 150
2 6 75% Average TUG test (sc) 39sc 22sc 8sc
3 Maximuma 100% Stairs-climbing test N/A 43sc 28sc
4 Maximumb Adjusted working weight 6-MW test N/A 702ft 1008ft
Single-leg stand test (left) N/A 2sc 7sc
a
Number of repetitions performed in the third set is used to determine the
weight of the fourth set according to the algorithm in Table 2. Clinical tests
b
Number of repetitions performed in the fourth set is used to determine Knee range of motion
the working weight for the third set at the next session according to the AROM 30–44 15–80 0–108
algorithm in Table 2. PROM 16–52 13–86 0–112
Quadriceps strength assessment
MMT 2/5 3/5 4/5
6-RM (lbs) 0 1.5 18
Knee girth (cm) 51.8 51 49.2
Table 2. Modified guidelines for determining adjusted working weight. NPRS (at rest) 6 5 2
Self-reported questionnaires
Adjusted working Adjusted working SF-36 (%) 93 93 99
Number of repetitions weight for the weight for the KOS-ADLS (%) 16.30 55 81.30
performed during set fourth seta next dayb
0–2 Decrease 2 pounds Decrease 2 pounds FIM, Functional independence measure; TUG, timed up-and-go; AROM,
3–4 Decrease 1 pound Keep the same weight Active Range of Motion; PROM, passive range of motion; 6-RM, six-
5–7 Keep the same weight Increase 1 pound repetition maximum; NPRS, Numerical Pain Rating Scale; SF-36, Short
8–10 Increase 1 pound Increase 2 pounds Form-36 Health Survey; KKOS-ADLS, Knee Outcome Survey–
11 Increase 2 pounds Increase 3 pounds Activities of Daily Living Scale. N/A, not assessed; sc, seconds, ft,
feet, lbs, pounds; cm, centimeters.
 DOI: 10.3109/09593985.2013.868064 A daily adjustable progressive resistance exercise 293
Table 4. Quadriceps strength assessment. that can be adjusted to numerous patients and rehabilitation
settings (Wilson, 2008). Therefore, to address the patient’s needs
6-RM and successful implementation of the technique to a TKA
Sited knee Supine terminal Straight rehabilitation program without increasing the risk of serious
Home physical extension knee extension leg raise muscular injury, the author customized the guidelines for
therapy visits MMT (lbs) (lbs) (lbs) determining adjusted ‘‘working weights’’ in the DAPRE system
1st 2/5 0 0 0 (Table 2).
2nd 2þ/5 0 0 0 The variation in repetitions from set to set, session to session and
3rd 3/5 0 0 0 week to week allows DAPRE training to work like undulating
4th 3/5 0 0 0 periodization which could explain its effectiveness. Rhea et al.
5th 3/5 1.5 4 0 (2003) reported that undulating periodization was more effective at
6th 3/5 2 4 0 improving strength and endurance as compared with LP. In
7th 3þ/5 5 7 2
8th 4/5 6 8 3
undulating periodization, the intensity and volume are changed
9th 4/5 6 9 4 more frequently as compared with more structured LP. A LP
10th 4/5 9 10 4 protocol may not be applicable to address the quadriceps impair-
11th 4/5 12 11 4 ments at early stages of rehabilitation following a TKA without
12th 4/5 13 13 5 endangering the quadriceps muscle by overloading it with exces-
13th 4/5 16 16 5 sive resistance due to its linear systematic progression. In addition,
Physiother Theory Pract Downloaded from informahealthcare.com by McMaster University on 03/31/15

14th 4/5 16 16 5
a LP does not address individual muscle strength differences and
15th 4/5 17 16 6
16th 4/5 18 16 6 especially daily quadriceps strength variations following a TKA.
The flexible nature of the DAPRE system makes it ideal for
MMT, manual muscle test; lbs, pounds. the rehabilitation settings regardless of the degree of the patient’s
deconditioning. The DAPRE system allows for maximum strength
gains to be attained in the quickest time possible without
endangering the patient by overloading his or her tissues and/or
joints with excessive resistance. For example, the strength phase
functional performance and quadriceps muscle strength a week of rehabilitation should be performed at approximately 80–88% of
after surgery. The patient made substantial improvements in both a patient’s 1-RM. Most patients cannot attain their true 1-RM in
quadriceps muscle strength and functional performance in the first the rehabilitation setting because of pain, tissue injury, and/or
seven weeks following surgery, a time frame that has typically post-operative restrictions. However, the DAPRE system does not
For personal use only.

been associated with a decrease in quadriceps strength, despite
rehabilitation (Walsh, Woodhouse, Thomas, and Finch, 1998).
Petterson et al. (2009) reported that exercises designed to
progressively strengthen the quadriceps significantly improved
knee functioning after knee replacement surgery. For this reason,
the therapist implemented an intensive rehabilitation protocol
using daily adjustable progressive exercises to address this
patient’s needs.
To my knowledge, this case report is one of the first to
investigate the effects of the DAPRE protocol on quadriceps
strengthening after TKA and certainly the first to report the
effectiveness of the protocol and its application to rehabilitation
of a patient following TKA.
The DAPRE technique and functional training were found to
be effective at improving quadriceps extension strength and
functional performance such as walking, balance, and stairs
climbing in this patient following TKA over five weeks. The
outcomes for this patient suggest that a DAPRE training may be
important to consider when choosing a protocol in home care
settings to elicit maximal quadriceps strength and functional
performance gains in post-op TKA patients.
Programs to systematically improve muscle strength were first
described in the research literature by DeLorme and Watkins
(1948), who developed a method known as progressive resistance
exercise (PRE) to overload the quadriceps progressively to
improve strength after femoral fractures. Knight (1990) and
Mann, Thyfault, Ivey, and Sayers (2010) modified the original
DeLorme’s PRE program for the rehabilitation of quadriceps
strength after knee surgery and developed the DAPRE method of
training. Furthermore, the treating physical therapist reduced the
working weights from their original version of 5 to 1 lb, 10 to 2 lbs
and 15 to 3 lbs, respectively. The original protocol was designed
to address the needs of the athletic population. There is
considerable lack of data in the geriatric rehabilitation literature
about the above-mentioned protocol design. However, the
DAPRE technique by itself is a reliable, valid, and flexible tool
require a 1-RM measure to be taken. Instead, the practitioner can
start off with a relatively light ‘‘working weight’’ and can feel
confident that the patient will reach his/her true 5- to 7-RM
workout within 2–3 sessions. The DAPRE system eliminates the
‘‘guesswork’’ in the initial prescription of resistance training
regimens as well (Wilson, 2008).
It was recommended that more progressive and high-intensity
exercises may be necessary to address lower extremity muscle
size, activation and strength deficits, along with functional
mobility early following surgery (Meier et al, 2008). Bade and
Stevens-Lapsley (2011) assessed the clinical outcomes of a high-
intensity rehabilitation programs compared with those of a group
of age-matched and sex-matched controls who underwent a low-
intensity rehabilitation program. The high-intensity rehabilitation
program consisted of resistive training with an adjustable ankle
weight, machine-based strengthening, and eccentric strengthening
(Bade and Stevens-Lapsley, 2011). Results of the Bade and
Stevens-Lapsley (2011) study indicated that utilization of a high-
intensity program initiated early in the course of recovery after
TKA led to superior strength and functional outcomes, without
increased pain or decreased knee ROM outcomes, in this small
group of patients. The clinical and performance-based outcomes
of this patient were consistent with Bade and Stevens-Lapsley
(2011) study’s results. The patient tolerated the DAPRE protocol
very well without complains of muscle soreness or additional
pain. This patient was chosen to strengthen the quadriceps muscle
with the DAPRE protocol because of her desire to return to a high
level of function, and therefore her motivation could also have
played a role in her rapid rate of improvement.
The initial rapid improvement in quadriceps strength follow-
ing the DAPRE protocol can be explained by a resolution of
activation deficits. Aagaard et al. (2010) reported that central
muscle activation may increase with strength training in the
elderly population. While an adaptation in neural control is
important for the improvements in strength during the first
1–2 months, significant muscle fiber hypertrophy occurs later
 294 G. Ardali
Figure 1. 6RM assessment of the quadriceps
strength in seated position.
Physiother Theory Pract Downloaded from informahealthcare.com by McMaster University on 03/31/15
Figure 2. Knee Outcome Survey-Activities of
For personal use only.
Daily Living Scale (%).
(Lexell, 2000). It was reported that about two decades of age-
associated loss of strength and muscle mass could be regained in
about two months of resistance training (Winett, Williams, and
Davy, 2009). For this reason, the patient was instructed to
continue the DAPRE home exercise program at least two months
after discharge from home physical therapy.
Functional performance on the SCT, TUG and 6MWT are
decreased prior to TKA in patients with end-stage knee OA
compared with healthy adults. Following recovery from TKA and
rehabilitation, patients have 105% longer SCT times, 63% longer
TUG times and 28% shorter 6MWT distances compared with
healthy adults of similar age (Bade and Stevens-Lapsley, 2011).
This patient made substantial improvement on the functional tests
as compared with the above data. Mean performance for the TUG
in this age group has been reported to be between 5.6 and 8.0 s
(Bade and Stevens-Lapsley, 2011), which indicates that this
patient had recovered to normative levels on this measure at seven
weeks after the surgery. Average performance by healthy adults
on the SCT is 8.9–1.7 s, and an average performance on the
Physiother Theory Pract, 2014; 30(4): 287–297
6MWT in this age group has been reported between 538 and
600 m (Bade and Stevens-Lapsley, 2011), indicating that the
patient made substantial improvement on these tests at seven
weeks post-op to achieve the normative levels.
The results of this present case report are consistent with the
aforementioned studies, suggesting that early introduction of an
intensive progressive resistive program in home health care may
be able to attenuate the significant loss of quadriceps torque and
improve function in the first seven weeks following a TKA.
Mahomed et al. (2008) recommend the use of home-based
rehabilitation services following elective primary knee replace-
ment as it is the more cost-effective strategy. In addition,
encouraging findings have been reported in favor of home-based
rehabilitation as compared with inpatient rehabilitation (Kramer
et al, 2003), even after early hospital discharge (Mahomed
et al, 2008). This case report provides promising preliminary
information on how a DAPRE rehabilitation program which
focused on extensor muscle strength deficits may improve the
quadriceps muscle strength and functional performance after
 DOI: 10.3109/09593985.2013.868064
a TKA. The modified DAPRE technique can offer an innovative
and cost-effective approach in home health care to potentially
resolve the quadriceps muscle and functional impairments
following a TKA. However, a larger group of patients must be
followed for a longer period to make conclusive statements about
the long-term benefits of this program for function and quadriceps
strength improvements. Research eliminating the confounding
factors such as functional training and other forms of quadriceps
strengthening methods from the rehabilitation program could
provide insight about the effects of the DAPRE technique on
quadriceps strength improvements in patients fallowing TKA.
Conclusion
This case report describes the use of the DAPRE protocol, in
addition to functional training, to enhance quadriceps muscle
strength and functional performance in an elderly homebound
patient following TKA. For this patient early initiation of a
Physiother Theory Pract Downloaded from informahealthcare.com by McMaster University on 03/31/15
DAPRE protocol was free of adverse events and appeared to
maximize quadriceps strength and functional performance. This
rehabilitation protocol may offer a novel technique of quadriceps
training to patients after a TKA. The positive gains of this patient
suggest that there is potential value in using this approach, and
further research is needed to determine the effects of the DAPRE
protocol in patients following a TKA.
Declaration of interest
The author reports no conflicts of interest.
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 DOI: 10.3109/09593985.2013.868064 A daily adjustable progressive resistance exercise 297

Appendix A. Phase I rehabilitation exercise program  Sit, with leg bent to 90 .
 Straighten the leg at knee.
First visit (post-op: 7 days)
 Return to starting position.
 Bedside exercises: ankle pumps, quadriceps sets and gluteal  Follow the DAPRE protocol.
sets.
 Knee range of motion (ROM): passive ROM (sitting) and heel
slides (supine). Terminal knee extension
 Bed mobility and transfer training (bed to/from chair).
 CPM: 2–4  day for 1–2 h.
 Ice and elevation after exercises or as needed.

Second visit (post-op: 9 days)

 Progression of CPM: 2–4  day for 1–2 h.
 Exercises for active ROM and active assisted ROM (sitting
using other lower extremity to assist).
 Strengthening exercises (e.g. ankle pumps, quadriceps sets,
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heel slides and short-arc quads) 2 sets of 10 repetitions for all

strengthening exercises, twice a day.
 Gait training with a rolling walker on level surfaces and
functional transfer training (e.g. sit to stand, surface-to-surface
transfers and bed mobility).  Place a rolled pillow under involved knee, allowing knee to
 Ice and elevation after exercises or as needed. bend about 45 .
 Straighten leg at knee.
 Return to starting position.
Third visit (post-op: 11 days)  Follow the DAPRE protocol.
 Progression of CPM: 2–4  day for 1–2 h.
 Progression of ROM with active, active assisted, passive and
stretching exercises. Straight leg raise
For personal use only.

 Progression of strengthening exercises to the patient’s

tolerance [hip abduction (standing), hamstring curls (standing),
sitting knee extension (without knee extension lag)], 2 sets of
10 repetition for all strengthening exercises, twice a day.
 Initiation of straight-leg raises, two sets of five repetitions.
 Progression of ambulation distance with emphasis on heel
strike, push-off at toe-off and normal knee joint excursions.
 Stairs training.
 Ice and elevation after exercises or as needed

 Lie on your back with uninvolved knee bent.

Appendix B. Phase II left knee extension strengthening  Raise straight involved leg to the thigh level of the bent knee.
exercises  Return to the starting position.
 Follow the DAPRE protocol.
Seated knee extension