What are the standard physiotherapy guidelines for Total Knee Replacement (TKR)?

Standard Physiotherapy Guidelines for Total Knee Replacement (TKR)

Neuromuscular electrical stimulation (NMES) should be used with standard treatment after TKR to improve function, though it shows no significant difference in pain outcomes. 1

Early Postoperative Phase (0-2 weeks)

• Early mobilization should be implemented immediately following TKR to improve early phase knee flexion and extension range of motion without compromising knee stability, regardless of graft type 1
• Isometric quadriceps exercises including static quadriceps contractions and straight leg raises can be safely prescribed during the first 2 postoperative weeks, providing faster recovery of knee range of motion without compromising stability 1
• Cryotherapy (ice/cold therapy) shows no significant difference in patient pain, function, and opioid use compared to control treatments, but may be used based on patient preference 1
• Massage may be used with standard treatment for improved pain outcomes 1

Intermediate Phase (2-6 weeks)

• Begin leg press exercises at 3 weeks post-operation to improve subjective knee function and functional outcomes 1
• Both open and closed kinetic chain exercises should be incorporated for regaining quadriceps strength, with no significant difference in anterior tibial laxity between these exercise types 1
• Open kinetic chain exercises can be started at week 4 from 90° to 45° of knee flexion and maintained until 12 weeks post-operation 1
• Monitor for anterior knee pain with open kinetic chain exercises, as they may induce more pain compared to closed kinetic chain exercises 1

Advanced Phase (6-12 weeks)

• Eccentric cycle ergometer training initiated at 3 weeks instead of 12 weeks post-operation results in greater strength gains, better daily activity level, and greater quadriceps muscle hypertrophy, with benefits persisting 1 year after surgery 1
• Implement both land-based and aquatic exercises based on patient preference and ability, with no demonstrated difference in benefits or safety between the two approaches 1
• Cardiovascular (aerobic) and/or resistance land-based exercise is strongly recommended for all TKR patients 1
• Weight loss interventions should be strongly recommended for all patients who are overweight 1

Exercise Components

• Quadriceps strengthening exercises are beneficial in the management of knee OA and post-TKR rehabilitation, with good evidence (1B) supporting their use 1
• Both aerobic fitness training and strengthening exercises show long-term benefits for pain and function 1
• Use both open and closed kinetic chain exercises for regaining quadriceps strength 1
• Incorporate eccentric training for greater strength gains and muscle hypertrophy 1

Additional Therapeutic Interventions

• Transcutaneous Electrical Nerve Stimulation (TENS) shows no significant difference in functional outcomes, pain, or opioid use compared to standard treatment 1
• Music therapy may be used with standard treatment to decrease postoperative pain and opioid use 1
• Guided relaxation therapy shows no significant difference in pain and opioid use outcomes compared to standard treatment 1
• Virtual reality (VR) shows no difference in patient outcomes compared to standard treatment 1
• Cognitive/behavioral treatment shows no significant difference in function or pain outcomes compared to standard treatment for TKR patients 1

Important Considerations

• Accelerated physiotherapy regimens can reduce acute hospital length of stay (by approximately 3.5 days) 2
• Strengthening and intense functional exercises, whether in land or water programs, with increasing intensity based on patient progress, should be included in outpatient physical therapy protocols 3
• For patients indicated for TKR who have completed trials of appropriate non-operative therapy, proceeding to TKR without delay is conditionally recommended over delaying surgery for additional physical therapy 1
• Delaying TKR for physical therapy may cause increased pain due to disease severity, though exceptions exist for non-ambulatory patients or those recovering from medical comorbidities that may limit postoperative rehabilitation 1

Common Pitfalls and Caveats

• Mandated physical therapy is not recommended to delay or avoid surgery for patients indicated for TKR 1
• Avoid delaying TKR for patients with moderate-to-severe OA who have already tried appropriate non-operative therapy, as this may lead to further pain, limitations in physical function, and increased risk of disability 1
• Be aware that open kinetic chain exercises might induce more anterior knee pain compared to closed kinetic chain exercises 1
• Monitor for anterior knee pain during exercise progression, particularly with open kinetic chain exercises 1