Special Focus Section 201

Rehabilitative Guidelines after Total Knee

Arthroplasty: A Review
Jaydev B. Mistry, MD1 Randa D. K. Elmallah, MD1 Anil Bhave, PT1 Morad Chughtai, MD1
Jeffrey Jai Cherian, DO2 Tanner McGinn, BS1 Steven F. Harwin, MD3 Michael A. Mont, MD1

1 Center for Joint Preservation and Replacement, Rubin Institute for
Advanced Orthopaedics, Baltimore, Maryland
2 Department of Orthopaedics, Philadelphia College of Osteopathic
Medicine, Philadelphia, Pennsylvania
3 Department of Orthopaedic Surgery, Beth Israel Medical Center,
New York, New York
Address for correspondence Michael A. Mont, MD, Center for Joint
Preservation and Replacement, Rubin Institute for Advanced
Orthopaedics, 2401 West Belvedere Avenue, Baltimore, MD 21215
(e-mail: mmont@lifebridgehealth.org; rhondamont@aol.com).

J Knee Surg 2016;29:201–217.

Abstract Rehabilitation following total knee arthroplasty (TKA) continues to pose a challenge for
both patients and providers. In addition, guidelines vary considerably between institu-
tions, which often leave therapy regimens to the discretion of the provider. The lack of

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clear guidelines for rehabilitation may contribute to inadequate recovery of strength
and range-of-motion, resulting in less optimal functional outcomes. Therefore, the aim
of this review was to highlight and discuss a variety of post-TKA rehabilitative modalities
currently available and to provide evidence regarding efficacy and practicality. Specifi-
cally, we assessed the role of and evidence for exercise therapy, aquatic therapy, balance
training, continuous passive motion, cold therapy and compression, neuromuscular
electrical stimulation, transcutaneous electrical nerve stimulation, and instrument-
assisted soft-tissue therapy. Additionally, we proposed general recommendations for
rehabilitation after TKA, and as we specifically described active and obese patients, we
Keywords have included guidelines for these subsets as well. Our review examines the various
► rehabilitation rehabilitative modalities to offer suggestions for recovery of strength and range-of-
► total knee motion after TKA, with a focus on the early incorporation of exercise therapy, balance
arthroplasty training, aquatic therapy, cryopneumatic therapy, neuromuscular electrical stimulation,
► therapy and transcutaneous electrical nerve stimulation. Dedication and commitment to
► outcomes rehabilitation may help patients attain and exceed their preoperative activity levels.

Total knee arthroplasty (TKA) is an excellent option for
patients suffering from end-stage arthritis,1,2 and its success
largely depends on surgical technique and implant longevity,
both of which have improved over the past several decades.3,4
For example, advances in perioperative interventions such as
the use of computer-assisted navigation and patient-specific
instrumentation, have demonstrated favorable outcomes and
are currently undergoing further investigation.5–7 Despite
these advancements, outcomes following TKA remain depen-
dent on the adequacy of rehabilitation and subsequent
functional recovery following surgery. For example, it has
been observed that quadriceps muscle strength may decrease
by up to 50 to 60% after the procedure and often fails to return
to preoperative levels.8–13 Although orthopedists and thera-
pists employ various techniques to address poor outcomes
following surgery, there is currently no consensus regarding
which rehabilitation protocols should be used for improved
functional outcomes.14,15
Rehabilitation after TKA focuses on recovery of knee
range-of-motion (ROM), restoration of knee- and hip-muscle

received Copyright © 2016 by Thieme Medical DOI http://dx.doi.org/

October 13, 2015 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0036-1579670.
accepted after revision New York, NY 10001, USA. ISSN 1538-8506.
January 31, 2016 Tel: +1(212) 584-4662.
published online
March 10, 2016
202 Rehabilitative Guidelines after TKA Mistry et al.
strength, development of functional independence, and the
ability to participate in recreational activities.16–18 These are
commonly used tangible and patient-reported measures to
assess postoperative function, and therefore, are often the
focus of rehabilitation.16–18 Without rehabilitation, function-
al independence and activity levels may not be recovered.
Numerous modalities are directed toward regaining strength
and function, including but not limited to physical therapy,
aquatic therapy, ice/compression, transcutaneous electrical
nerve stimulation (TENS), neuromuscular electrical stimula-
tion (NMES), and instrument-assisted soft-tissue therapy.
Different rehabilitation programs, select modalities for their
patients based on practitioner preference, often with little to
no explanation of the reason for selection.14,19
With the availability of a large number of postoperative
rehabilitative modalities, determining the most suitable regimen
is often difficult. More importantly, there are no consistent or
widely implemented guidelines for rehabilitation after TKA,18,20
however, several other reviews21,22 have attempted to address
this topic. While they offer valuable insight into rehabilitation
following TKA, they did not include several available rehabilita-
tive modalities and only provided recommendations for the
general population. These reviews will be further described in
the discussion. Our report will add to the literature by providing
a comprehensive review that includes more rehabilitative
modalities. Additionally, this report will offer recommendations
for obese and active patients, as they are growing subsets of the
population. Therefore, our purpose was to: (1) evaluate the
various modalities for post-TKA rehabilitation; (2) specifically
evaluate differences in rehabilitation for obese and active
patients; and (3) propose guidelines for rehabilitation after
TKA for return to activity or sport.
Methods
A literature search using PubMed, EBSCO Host, and SCOPUS was
performed for this review. We searched studies from the incep-
tion of the respective databases up to July 2015. Various
combinations of the following search terms were applied:
(knee), (total knee arthroplasty), (knee replacement), (TKA),
(TENS), (transcutaneous electrical nerve stimulation), (NMES),
(neuromuscular electrical stimulation), (rehabilitation),
(Astym), (exercise therapy), (physical therapy), (aquatic),
(CPM), (continuous passive motion), (balance), (cryopneumatic),
(compression), (ice), (activity), (obesity), and (protocol).
Our search identified 750 abstracts, which were re-
viewed by two authors (J. M., M. C.) to determine articles
that were appropriate for this report. A consensus for any
uncertainties was reached with the help of a third author
(R. E.). A total of 211 potentially relevant articles were
identified for further evaluation. Overall, 120 articles were
determined not to be relevant to rehabilitative modalities
and outcomes after TKA or were not in English, and were
subsequently excluded. References of the remaining ar-
ticles were assessed, and those with potentially relevant
titles were selected to review their abstracts. This provided
an additional 28 articles. A total of 119 reports were
included in this review.
The Journal of Knee Surgery Vol. 29 No. 3/2016
The following rehabilitative modalities were chosen as a
result of the relevance criteria set before the search and
because they have been frequently utilized in other reviews:
Exercise therapy, aquatic therapy, balance training, continu-
ous passive motion, cold therapy and compression, neuro-
muscular electrical stimulation, transcutaneous electrical
nerve stimulation, and instrument-assisted soft-tissue thera-
py (see ►Appendix 1 for a summary of the studies).
Exercise Therapy
Exercise therapy plays a fundamental role in the postopera-
tive rehabilitation of patients after TKA. Different protocols
provide various instructions for the progression of therapy
after surgery, however, health care professionals often use
their clinical judgment to make adjustments to optimize
results. Common elements in post-TKA exercise therapy
include, but are not limited to: passive knee ROM exercises,
lower extremity stretches (for the quadriceps, hamstrings,
and calf), ice/heat application, gait training, and functional
training.23 When exercise protocols are designed, many
aspects may vary from therapist to therapist, including
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duration of the regimen and type of exercise included. As
such, there is no “usual care” for patients, which highlights
the weakness that many studies do not sufficiently describe
“standard rehabilitation.” Bhave and Baker describe a three-
phase physical therapy protocol encompassing the elements
of strengthening, ROM, and functional recovery
(see ►Appendix 2). This protocol highlights basic strength-
ening exercises, ROM stretches, and gait training, among
others. Another set of exercises that are commonly used is
the SAFTE (slide and flex, tighten, and extend) regimen,
however, it is not used by all.24 While seated in a chair, the
patient is instructed to slide the foot back, bending the knee
as much as possible. Keeping the foot stationary, the patient
then leans back and slides the buttock forward, causing the
knee to flex further. Next, the patient is to sit with the knee
extended and heel on the floor with the ankle in dorsiflexion.
The patient should tighten the thigh muscle as if pushing the
knee downward, holding for 5 seconds before relaxing. While
in the relaxed position, patients are also encouraged to gently
move the patella from side-to-side.
Several studies have evaluated the use of different reha-
bilitation programs for post-TKA patients. Petterson et al25
conducted a randomized clinical trial (RCT) with a two-arm
progressive strength training program (n ¼ 92, RCT group),
one of which utilized NMES, and compared the results with a
cohort of patients who received the standard rehabilitation
protocol after TKA. While they were unable to discern signifi-
cant differences for any outcome variable between the two
RCT groups, they found that both arms of the strengthening
protocol collectively produced significantly better 12-month
outcomes when compared with the standard rehabilitation
cohort. The RCT group had significantly greater quadriceps
strength (p ¼ 0.007), was 24% faster on the timed-up-and-go
test (TUG) (p ¼ 0.004), completed the stair-climb time (SCT)
test 44% faster (p < 0.001), and walked a 15% greater distance
on the 6-min walk (6MW) (p ¼ 0.003). Additionally, Bade and
Stevens-Lapsley23 conducted a prospective cohort study to

assess the outcomes of a high intensity (HI) rehabilitation
program compared with a lower intensity rehabilitation
program. They concluded that a HI program leads to better
short-term (p < 0.05) and long-term (p < 0.05) functional
performance when compared with the control group. The HI
group also demonstrated better short-term (p < 0.05) and
long-term (p ¼ 0.08) quadriceps strength.
Moffet et al26 compared a new intensive functional reha-
bilitation (IFR) program with a control group who received
usual care (which was not defined). Four to six months after
TKA, the IFR group demonstrated significantly greater im-
provements in the 6MW distance (p ¼ 0.029), total Western
Ontario and McMaster universities arthritis index (WOMAC)
(p ¼ 0.007), and WOMAC pain score (p ¼ 0.001). There were
no significant differences between groups at the 1-year mark.
Despite the success and encouraging results of the IFR group,
they were unable to attain the same level of functional ability
as healthy age-matched individuals. By 12 months, only 30 of
69 patients (43.5%) who completed the study had a 6MW
performance within normal ranges (mean, 448 m; 95% confi-
dence interval, 423–473 m), of which 20 received IFR training.
Evgeniadis et al27 investigated the effects of a preoperative
or postoperative rehabilitation program for patients before
and after primary TKA. A total of 72 patients were random-
ized into three groups; a control group, a group that received
3 weeks of preoperative strengthening exercises with a focus
on the core and upper extremities, and a group that received
8 weeks of home-supervised rehabilitation for the lower
extremity. Subjects in all three groups received standard
inpatient rehabilitation that lasted 12 to 14 days. Parameters
measured were functional ability (using the Iowa level of
assistance scale) and active ROM of the knee at the 10th and
14th weeks after TKA. At 10 weeks after surgery, patients in
the postoperative exercise group demonstrated greater flex-
ion (p < 0.01), extension (p < 0.01), and functional ability
(p < 0.001) compared with the control and preoperative
groups. At 14 weeks after surgery, the postoperative exercise
group continued to have significantly greater knee ROM
(p < 0.01 for both flexion and extension) compared with
the two other groups. Although ROM was effectively in-
creased in this group, they were only able to achieve 98.42
and 0.8 degrees of flexion and extension, respectively.
Previous studies have indicated that restoration of at least
110 degrees of knee flexion is necessary for satisfactory
function and to complete most daily activities.28–30 Knee
flexion contractures resulting in ROM reduction occur in 1
to 15% of primary TKA patients and can cause significant
functional limitations.31,32 In a study conducted at the au-
thor’s institution,33 47 patients with knee flexion contrac-
tures (mean, 22 degrees; range, 10–40 degrees) after primary
or revision TKA were treated with a custom knee device in
supervised therapy sessions. After a mean treatment time of
9 weeks (range, 6–16 weeks), 27 of 29 patients who received
primary TKAs achieved full extension, which was preserved
at an 18-month follow-up. In all patients, knee society knee
scores and functional scores improved from 50 to 91 points
and 34 to 89 points, respectively. Compared with other
nonoperative regimens in the literature,34–39 this knee
Rehabilitative Guidelines after TKA Mistry et al. 203
extension protocol demonstrated similar rates of improve-
ment with decreased treatment time, suggesting its utility in
this common obstacle encountered during rehabilitation.
Invasive modalities, such as botulinum toxin injections and
soft-tissue releases, are available for the management of knee
flexion contractures but are beyond the scope of this review.
In summary, the primary purpose of exercise therapy is to
maximize early ROM, improve strength and pain, and to
normalize gait mechanics. While there is much debate as to
the use of an appropriate regimen, there is a consensus that
postoperative exercise should consider patient-specific goals
in addition to having a long-term focus on strength and
function.22
Aquatic Therapy
Aquatic therapy after TKA has recently gained popularity, as it
is believed that the buoyancy of water attenuates the effects of
gravity, decreasing shear, and compressive forces in joints.40
In addition, the water resistance improves strength, particu-
larly as its intrinsic property to resist movements increases
with speed.21,41 This may be more advantageous in the early
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postoperative phase when patients are limited by pain, and
fortunately these therapy programs can begin anywhere from
4 days to 18 months after TKA.40 Aquatic exercises may
include ROM stretches for the hip, knee, and ankle; single
leg balance, mini-squats, cycle kicks, and leg swings.40,42
Valtonen et al40 conducted a RCT to study the effects of
aquatic resistance training on mobility, muscle power, and
cross-sectional area (CSA). A total of 50 patients were
randomly assigned to either a 12-week progressive aquatic
resistance-training program (n ¼ 26) or were advised to
maintain their usual level of activity (n ¼ 24). At the end of
12 weeks, the average rate of perceived exertion was esti-
mated to be 17 (0 ¼ no effort; 20 ¼ maximum effort) in six
patients in the aquatic training group. Patients in the aquatic
training group increased their habitual walking speed by 9%
(p ¼ 0.005) and decreased their SCT by 15% (p ¼ 0.006). This
group also increased knee flexor and extensor power in the
operated leg by 48% (p ¼ 0.003) and 32% (p < 0.001), respec-
tively. The mean thigh muscle CSA in the experimental group
increased by a mean of 3% (p ¼ 0.018) in the operated leg and
2% (p ¼ 0.019) in the nonoperated leg compared with con-
trols. There were no differences in the WOMAC scores
between groups. However, significant changes were lost at
1-year follow-up, which may indicate the importance of
continuing aquatic rehabilitation strategies over the long-
term to prevent the loss of training-induced benefits.43
Conversely, Harmer et al44 randomized 102 patients after
TKA to participate in a 6-week land-based (n ¼ 49) or water-
based (n ¼ 53) exercise program. Patients in both groups
were assessed by the same examiner starting from 2 weeks
after surgery (baseline) and at 8 and 26 weeks after surgery.
While both training groups improved significantly from
baseline, no differences were noted between groups with
respect to WOMAC score, knee ROM, 6MW, and SCT.
In summary, some studies have demonstrated comparable
or greater benefits with the use of aquatic therapy compared
with standard exercise programs, particularly as buoyancy
The Journal of Knee Surgery Vol. 29 No. 3/2016
204 Rehabilitative Guidelines after TKA Mistry et al.
decreases forces within the knee joint, which may allow
patients to experience some relief of pain.
Balance Training
Patients often have impaired balance after TKA as a result of
ligamentous damage that alters mechanoreceptors. This af-
fects joint proprioception and postural control, which in turn
influences knee stability.45–47 These deficits affect the ability
of patients to perform activities such as twisting, pivoting,
walking on uneven surfaces, and changing direction. To aid
with this, balance training may be employed, which includes
lower extremity ROM exercises and functional task-oriented
exercises with resistance bands, sidestepping, tandem walk,
and use of a tilt board or balance beam.48,49
In a double-blinded, RCT conducted by Piva et al,45 it was
determined that patients who received 6 weeks of balance
training in addition to their functional training demonstrated
faster gait speed and better results on a single leg balance test
than those who only received functional training. In a pro-
spective RCT, Liao et al,50 randomly assigned 113 patients to
either an experimental group (n ¼ 58) that received standard
functional training with additional balance exercises, or a
control group (n ¼ 55) that received only standard functional
training. The standard functional training exercises were
based on existing protocols in the literature,26 as were the
balance exercises.48,49 Upon completion of the 8-week inter-
vention, the experimental group demonstrated significant
improvement in all categories (p < 0.001) including the
timed 10-minute walk, TUG, and WOMAC. Conversely, Fung
et al,51 conducted a RCT to determine whether a gaming
console (Nintendo Wii Fit, Nintendo Co., Ltd., Kyoto, Japan)
can be used as a supplement to physiotherapy treatment in
the recovery of balance, strength, function, and lower
extremity movement following TKA. In addition to a physio-
therapy session, the control group received 15 minutes of
lower extremity and strengthening exercises while the
experimental group received 15 minutes of game console
activities that encouraged multidirectional movements. No
significant differences were observed in pain, knee flexion,
knee extension, walking speed, timed-standing tasks, lower
extremity functional scale, or patient satisfaction between
the two cohorts (p > 0.05). These results suggest that
application of interactive home video games that challenge
balance and postural control of the lower extremities may
potentially serve as a comparable substitute to standard
physiotherapy sessions for TKA patients.
In summary, studies have demonstrated that balance
training may aid in postoperative functional recovery and
rehabilitation. These improvements have the potential to
restore joint proprioception and postural control. While there
are various ways to supplement post-TKA rehabilitation with
balance training, there are no clear protocols on the use of
these exercises.
Continuous Passive Motion
Continuous passive motion (CPM) is a machine that repeat-
edly provides passive movement of the knee joint through a
controlled ROM and has been a staple modality in the
The Journal of Knee Surgery Vol. 29 No. 3/2016
recovery of TKA patients.52 It is postulated to have healing
effects on articular cartilage and ligaments, as well as shorten
hospital stay, improve ROM, and lead to fewer circulatory
complications.52–54 With the use of CPM, the patient should
aim to achieve at least 0 to 90 degrees ROM upon hospital
discharge and 0 to 120 degrees upon completion of postop-
erative rehab.55 Several studies have demonstrated improve-
ments with CPM use. A retrospective study conducted by
Romness and Rand54 retrospectively compared patients who
received CPM post-TKA with a control group who only
received a bulky compression dressing. They found that the
CPM group had significantly greater knee flexion at discharge
compared with the control group (90 vs. 88 degrees;
p < 0.02). Additionally, the treatment group was able to reach
90 degrees of flexion in 7.7 days while the control group
required 10.3 days (p < 0.001). While the CPM group had a
greater mean post-operative wound drainage compared with
the control group (630 vs. 499 mL, p < 0.02), there was no
significant difference in the length of hospital stay after TKA.
McInnes et al56 also conducted a RCT comparing CPM plus
standard rehabilitation to standard rehabilitation alone.
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At 7 days postoperatively, the CPM group had higher
active flexion compared with the non-CPM group (82 vs.
75 degrees; p ¼ 0.004), as well as less swelling (p ¼ 0.0008),
but no significant differences were observed in active and
passive extension (p > 0.05).
Conversely, other studies have highlighted no significant
advantages with the use of CPM. Pope et al57 performed a RCT
in 53 patients, who were divided into one of three groups: no
CPM, CPM from 0 to 40 degrees, and CPM from 0 to 70 degrees.
At 1 year postoperatively, no significant differences were
found between the groups in regards to mean flexion, func-
tional score, ROM, or fixed flexion deformity, however, it was
noted that patients in the CPM group required significantly
more analgesic medications (p ¼ 0.04). In addition, postop-
erative blood drainage was significantly higher in the 0 to 70
CPM group compared with the 0 to 40 CPM (p ¼ 0.01) and no
CPM (p ¼ 0.005) groups. Similarly, Maniar et al58 evaluated
patients who received no-CPM, 1-day CPM, or 3-day CPM
regimes and found no statistically significant differences in
TUG, WOMAC, short form-12, ROM, and wound healing. In
fact, knee swelling (as measured by suprapatellar girth)
decreased at a slower rate in the CPM groups as compared
with the control group. By day 42, the suprapatellar girth in
the control group returned to preoperative levels while
significant swelling persisted in the 1-day CPM (p ¼ 0.009)
and 3-day CPM (p < 0.001) groups. Joshi et al59 also noted no
significant differences in knee flexion between patients who
received only physiotherapy and patients who received CPM
and physiotherapy at 6 weeks (p ¼ 0.69) or 3 months
(p ¼ 0.41). While both groups individually demonstrated
significant improvement in WOMAC score at 6 weeks (both
groups p < 0.01) and three months (both groups p < 0.01),
there were no significant between-group differences in their
scores at those times (p ¼ 0.41 and 0.18, respectively). Mau-
Moeller et al55 evaluated the effect of CPM and a new sling
exercise training program (ST) on clinical and functional
outcomes after TKA. Patients in the CPM group received

physiotherapy and CPM application while the ST group
received physiotherapy and performed sling exercises.
Patients in the ST group demonstrated significantly higher
passive flexion ROM by 6 degrees compared with the CPM
group 1 day before discharge (p ¼ 0.022), however, no differ-
ence was documented at the 3-month follow-up visit. Given
the ease at which sling therapy can be performed and its cost-
effectiveness compared with CPM, further research is
warranted to assess its value and degree of clinical outcomes
as a modality of post-TKA rehabilitation.
In summary, CPM has been a long-standing approach
utilized in the recovery of TKA patients. While some may
argue for the benefits of CPM in the acute in-patient phase, its
degree of long-term advantage still remains controversial.59
More recent literature has suggested that CPM use may be
associated with increased postoperative blood drainage, in-
creased analgesic use, and persistent swelling. As a result of
this new evidence, orthopedists should assess if CPM use will
have a positive impact on patient recovery.
Cold Therapy and Compression
The use of cold and compressive therapy has been tradition-
ally implemented after TKA to mitigate pain, swelling, and
inflammation of the affected joint. Cold therapy, or cryother-
apy, slows the enzymatic function and induces vasoconstric-
tion of the perioperative tissues.60 It also reduces leukocyte
migration and attenuates nerve signal transmission, produc-
ing a temporary anesthetic and analgesic effect.61 Studies
have demonstrated a positive correlation between local
temperature and synovial prostaglandin E2, a known marker
of pain and inflammation.62 External compression is thought
to prevent edema by increasing interstitial pressure and
reducing the flow of fluid into the interstitial space. In
addition to providing soft-tissue support, compressive dress-
ings can limit the volume of the intra-articular space, reduc-
ing the accumulation of hemarthroses.60,63
Levy and Marmar60 conducted a prospective RCT compar-
ing post-TKA patients who received cold compressive dress-
ings to a control cohort who received dressings alone (gauze
pads [Webril, Covidien, Dublin, Ireland, and Ace bandage
[Hemovac Zimmer Biomet, Warsaw, Indiana]). By postopera-
tive day (POD) 3, patients in the treatment group demon-
strated significantly less blood loss (548 vs. 807 mL as
measured by Hemovac output) and a significantly smaller
net hemoglobin drop (3.1 vs. 4.7 mg) (p < 0.001 for both)
compared with the control group. Additionally, the cold
compression group used less morphine per kilogram per 48
hours (p < 0.005) and demonstrated better visual analog
scale (VAS) scores during PODs 1 to 3 (p < 0.01 for POD 2,
and p < 0.05 for POD 3). They also had a significantly greater
total arc ROM in comparison to the control group on POD 7
(p < 0.05) and POD 14 (p < 0.01). Similarly, Su et al63 ran-
domized 280 patients to either a treatment group that
received a cryopneumatic device, or a control group that
received ice with static compression. While neither group
exhibited any significant difference in ROM, 6MW, TUG, or
knee girth compared with each other, postoperatively, the
treatment group used a significantly lower amount of narcot-
Rehabilitative Guidelines after TKA Mistry et al. 205
ic compared with the control group (509 vs. 680 mg mor-
phine equivalents) during the same period (p < 0.05).
Treatment group patients also reported greater satisfaction,
with regards to pain control and stiffness relief, than the
control group (p < 0.0001).
In contrast, Bech et al64 found no additional benefit of
consistent cooling via a motorized icing device in comparison
to intermittent cooling using an ice bag within the first
48 hours after TKA. Significant differences were not observed
between the control and intervention groups with regards to
pain, nausea or vomiting, passive ROM, or opioid use despite
significant differences in patient-reported satisfaction and
compliance. The intervention group demonstrated greater
satisfaction (8.4 vs. 6.0, p ¼ 0.002) and greater compliance
both at day and night (86 vs. 30% and 88 vs. 31%, respectively;
p < 0.001 for both), which the authors suggest may be due to
the convenience and ease of using an automated device.
In summary, most studies suggest that cryopneumatic
therapy is effective for postoperative pain relief and function,
particularly as it decreases the metabolic activity of local
tissues while providing external support and limiting the
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accumulation of soft-tissue swelling.62 However, the exact
routine of postoperative application may differ from surgeon
to surgeon.
Neuromuscular Electrical Stimulation
NMES is a noninvasive modality that employs the use of dosed
electrical currents delivered through cutaneous electrode
pads to stimulate muscle contraction.65 It may have the
potential to augment muscle strength and functional perfor-
mance, by overriding deficits in muscle activation caused by
central nervous system impairments.66–69 It is thought to
recruit a greater proportion of type II fast-twitch muscle
fibers, which generates higher levels of force production
and may correspond to better functional performance and
recovery.65,69–73 This is particularly important as failure of
voluntary quadriceps muscle activation is a major source of
weakness and can result from either an inability to utilize all
available motor units or a reduction in the peak motor unit
discharge rate from the recruited units.74 Voluntary quadri-
ceps activation deficit can result from swelling, joint damage,
and pain, and has been linked to decreased gait speed,
increased SCTs, impaired balance, and an increased risk of
falls.75–78 As a result, devices such as NMES have been
investigated in the use of post-TKA muscle weakness.
In a prospective longitudinal RCT, Stevens-Lapsley et al79
compared the efficacy of combined quadriceps NMES and
standard rehabilitation (n ¼ 35) with standard rehabilitation
alone (n ¼ 31) following TKA. The intervention group initiat-
ed NMES on POD 2 and received 15 contractions twice daily
for a total of 6 weeks. At 3.5 weeks postoperatively, the NMES
group had significantly better quadriceps strength
(p < 0.001), hamstring strength (p ¼ 0.04), 6MW
(p < 0.001), SCT (p ¼ 0.001), TUG (p ¼ 0.003), and extension
active ROM (p ¼ 0.01) compared with the control group, and
these improvements were maintained at 12 months
(p < 0.05). Compared with baseline, the quadriceps strength
of the NMES group at 12 months improved 11% more than
The Journal of Knee Surgery Vol. 29 No. 3/2016
206 Rehabilitative Guidelines after TKA Mistry et al.
that of the control group (p < 0.05). Moreover, the NMES
group demonstrated significantly better 12-month outcomes
for hamstring strength, SCT, TUG, and 6MW (p < 0.05 for all).
Avramidis et al80 conducted a similar prospective RCT evalu-
ating 70 patients who received either NMES and physiother-
apy or physiotherapy alone. Compared with the control
group, the NMES group demonstrated a significantly greater
improvement in walking speed for the 3-minute walk test at
6 weeks (p ¼ 0.003) and 3 months (p ¼ 0.001), however, this
difference was not maintained at 12 months. The NMES group
also had significantly greater short form-36 (SF-36) physical
component scores and knee society function scores at
6 weeks, 3 months, and 1 year after TKA (p ¼ 0.001 for all).
Conversely, there is evidence suggesting that NMES offers
no significant benefit in post-TKA patients. In the previously
mentioned study by Petterson et al,25 no significant differ-
ences were found in any of the assessed outcomes (strength,
SF-36 physical and mental, or performance based tests;
p > 0.08 for all after adjusted for baseline values) between
the progressive strength training group (n ¼ 45) and the
joint NMES-progressive strength training group (n ¼ 47). In
a single-center, RCT comparing NMES paired with at-home
ROM exercises to therapist-managed physical therapy, Lev-
ine et al81 observed noninferiority at 6 months for all
parameters (flexion, extension, knee society score pain/
function, WOMAC, TUG). Despite these reports suggesting
no long-term advantage of NMES use, it is worth noting that
they highlight the benefits of early NMES. The time course for
initiating NMES as well as its frequency of application vary
from study to study, and therefore, may explain differences in
findings.
In summary, patients who are unable to voluntarily acti-
vate the quadriceps muscle immediately after TKA may
benefit from early intervention with NMES. It can be easily
administered following basic instruction and has the poten-
tial to mitigate loss of quadriceps strength. Differences in the
design of NMES protocols may result in conflicting findings.
Further research is needed to determine specific parameters
of NMES, such as duration, timing, and intensity, and to also
establish its long-term impact on patient outcomes.
Transcutaneous Electrical Nerve Stimulation
TENS is a device where adhesive electrodes are placed on the
skin, sending controlled electrical impulses to local sensory
nerves.82 It is believed that TENS acts on central and periph-
eral nervous system mechanisms to promote an analgesic
effect.83 Specifically, it is thought to activate endogenous
opioid receptors in the spinal cord and brainstem, triggering
inhibitory centers to decrease sensitivity of the central
nervous system.84–87 As pharmacological measures do not
always provide adequate pain relief during rehabilitation,
these devices have been considered as an alternative analge-
sic modality.
Stabile and Mallory88 prospectively evaluated the use of
placebo TENS (electrode pad placement with no current
applied) (n ¼ 22), actual TENS (n ¼ 43), or intramuscular
hydromorphone (control, n ¼ 42) in post-TKA patients, and
it was observed that the placebo TENS and actual TENS group
The Journal of Knee Surgery Vol. 29 No. 3/2016
required less pharmacological pain control (p ¼ 0.05).
Despite these promising results, the authors did not compare
pharmaceutical use between the placebo TENS and actual
TENS groups. Similarly, Rakel et al82 conducted a randomized
placebo control trial that separated patients into cohorts
receiving TENS (n ¼ 122), placebo TENS (n ¼ 123), or the
standard of care (n ¼ 72). It was observed that the supple-
mentation of TENS with pharmacological pain control re-
sulted in a significant reduction of pain during movement
(p ¼ 0.019) and during gait speed testing (p ¼ 0.006) com-
pared with the standard of care group.
Conversely, there are studies suggesting that TENS has no
effect on pain relief. In a double blinded, placebo controlled
trial, Breit et al89 randomized patients to receive patient-
controlled analgesia (PCA, n ¼ 22), PCA and TENS (n ¼ 25), or
PCA and placebo TENS (n ¼ 22). There were no significant
differences in the use of sedation, spinal anesthesia, or
morphine, or VAS scores between the three groups
(p > 0.05). Furthermore, Angulo et al90 evaluated patients
who received sensory threshold TENS (n ¼ 18), subthreshold
TENS (n ¼ 18), or no TENS at all (control, n ¼ 12). All three
Downloaded by: Universite Laval. Copyrighted material.
groups received CPM during their hospitalization. Although
the two cohorts receiving TENS had improved VAS scores
during POD 1 to 3, there were no significant differences
between groups for pain relief, hospital stay, knee flexion
arc, or narcotic dosage (p > 0.05 for all). This suggests that the
use of TENS may provide only subjective pain relief.
In summary, as a pain relief modality, TENS has been
gaining popularity among patients despite the presence of
contradictory results in the literature. Its exact mechanism of
analgesia is more complex than we currently understand,
however, its ease of use and potential for facilitating func-
tional recovery warrant further trials.
Instrument-Assisted Soft-Tissue Therapy
Instrument-assisted soft-tissue therapy, specifically Astym
therapy (Performance Dynamics, Muncie, IN), is a noninva-
sive technique aimed to stimulate soft-tissue regeneration
through the application of pressure to the affected area.91 In
theory, this aids in fibroblast recruitment and activation from
dysfunctional capillaries, which stimulates the endogenous
release of growth factors and cellular mediators, leading to
fibrotic resorption and tissue regeneration.92,93 In vivo stud-
ies in rats have further demonstrated that fibroblast prolifer-
ation due to this form of treatment results in the production
of fibronectin, an important component in cellular signaling
for normal collagen organization, extracellular matrix forma-
tion, and soft-tissue healing.91,94,95 This technique has been
used for the treatment of post-TKA stiffness, which is a
debilitating complication that may lead to decreased ROM,
activity limitations, and constant pain in up to 15% of the
patients.31,32,96,97
The standardized process for this treatment method in-
volves three components: (1) the assessment and treatment
of the entire kinetic chain to address particular patterns of
fibrosis and dysfunctional soft tissue; (2) functional exercises
to promote healthy, appropriate alignment of new collagen
deposition capable of withstanding mechanical stresses; and

(3) detecting and minimizing inappropriate fibrosis that may
be causing irritation or mobility restrictions.92
In summary, while this modality has shown promising
results in the treatment of various chronic orthopedic
pathologies,93,98–100 such as tendinopathy and joint pain,
evidence has yet to be published regarding its use in the
treatment of knee joint stiffness. Further research in this
area is warranted to determine its efficacy as an acceptable
rehabilitation modality for post-TKA patients. At the
author’s institution, this treatment is used on patients
who cannot attain knee flexion past 90 degrees or knee
extension past 15 degrees. Our early results indicate that
this is a very useful modality for patients with reduced ROM
at 4 to 6 weeks postoperatively.
Special Circumstances: Obese and Active Patients
Obese Patients
Obesity is a well-known risk factor for knee osteoarthritis and
may increase a patient’s susceptibility for end-stage osteoar-
thritis requiring TKA.101 In fact, as the prevalence of obesity
rises as a nationwide epidemic, it stands to reason that this
population comprises a large proportion of patients under-
going TKA.102 Patients categorized as “obese” fit the widely
accepted definition of body mass index (BMI) greater than
30,101 while others are categorized as “highly obese” and
“morbidly obese” if their BMIs exceed 35 and 40,
respectively.103
Numerous studies assessing outcomes of TKA in the obese
patient have demonstrated conflicting results and subse-
quently generated much controversy regarding perioperative
risks, implant longevity, complications, and outcomes.
Samson et al104 conducted a literature review evaluating
TKA in patients with BMI > 40. In the eight comparative
studies that were examined, patients experienced overall
improvements in outcome measures postoperatively, how-
ever, higher complication rates were observed in all morbidly
obese groups. These patients had a greater prevalence of deep
periprosthetic infections (3–9 times higher) and wound
complications. Amin et al105 compared the results of 41
morbidly obese patients (BMI > 40) with that of a matched
cohort of 41 nonobese patients (BMI < 30) after TKA. At less
than 4 years after surgery, the morbidly obese group exhib-
ited worse results compared with the nonobese group, as
demonstrated by inferior knee society scores (mean knee
score 85.7 vs. 90.5, respectively, p ¼ 0.08; mean function
score 75.6 vs. 83.4, p ¼ 0.01), higher incidence of radiolucent
lines on postoperative radiographs (29 vs. 7%, p ¼ 0.02),
higher rate of complications (32 vs. 0%, p ¼ 0.001), and
inferior survivorship using revision and pain as endpoints
(72.3 vs. 97.6%, p ¼ 0.002). Hamoui et al106 demonstrated
that moderate obesity, defined as BMI 30 to 35, has no effect
on the clinical and radiological outcome after TKA. Compared
with patients with BMI > 30, there was no statistical signifi-
cance with regards to median knee society scores, presence of
radiolucent areas, evidence of osteolysis, revision rates, and
patient survival. The authors acknowledge that while their
results in moderately obese patients were similar to those of
Rehabilitative Guidelines after TKA Mistry et al. 207
normal weight patients after TKA, weight loss measures
should still be encouraged both pre- and postoperatively.
Obesity is often linked with other comorbidities, contrib-
uting to an increased risk for complications after TKA. These
complications include, but are not limited to, coronary artery
disease, hypertension, diabetes mellitus, sleep apnea, and
hyperlipidemia.107 Optimizing patient outcomes require
treatment that may need to begin before TKA. Weight loss
greater than 10% of one’s body weight can reduce their risk of
knee osteoarthritis to that of the nonobese population,
thereby minimizing the need for joint arthroplasty.108 These
interventions, whether dietetic, pharmacological, or other-
wise, should persist postoperatively to reduce obese patients’
weight in the long-term to maximize functional recovery and
implant longevity.
In summary, current studies demonstrate varying, and
often times, conflicting outcomes in obese TKA patients.
Further work is necessary to evaluate whether specific
modalities can yield better postoperative outcomes in this
growing patient subpopulation.
Downloaded by: Universite Laval. Copyrighted material.
Active Patients
With advancements in surgical technique, component tech-
nology, and surgeon experience, a growing number of TKAs
are being performed in younger patients, and many have
expectations to return to their full level of physical activity
following rehabilitation.109 However, specific guidelines
regarding return to activity of post-TKA patients remain
unclear.
An important factor to consider is the level of demand of
the activity, and whether it is low-, intermediate-, or high-
impact. As such, patients should address their particular
interests with their surgeons to determine the best recom-
mendation. Generally, most orthopedists recommend
conservative, low-impact activities such as cycling, walking,
swimming, and golf.110,111 Higher impact activities, such as
football, basketball, and soccer are usually discouraged
because orthopedists are concerned that an increased joint
load may cause accelerated implant wear and debris forma-
tion, leading to periprosthetic osteolysis and prosthetic fail-
ure.112,113 However, there is no consensus for many activities,
such as power walking, hiking, tennis, or jogging.110
Several studies have shown that activity levels after TKA do
not negatively impact outcomes. Jones et al114 conducted a
case–control study examining 26 patients with primary TKAs
followed by revisions compared with 26 patients with TKAs
who did not undergo revision. It was noted that both groups
engaged in low-impact activities. They determined that
physical activity is not a risk factor for revision TKA, and
that patients should be encouraged to maintain activity levels
following TKA. Mont et al115 conducted a midterm follow-up
study comparing clinical and radiographic outcomes of 50
patients engaged in at least 4 years of high-impact activity
with an age- and sex-matched cohort of 50 sedentary
patients. The high-impact activities in this study included
tennis, golf, skiing, and cycling or jogging. At a mean 7-year
follow-up, each group demonstrated one clinical failure, two
revisions, and no progressive radiolucencies. The authors
The Journal of Knee Surgery Vol. 29 No. 3/2016
208 Rehabilitative Guidelines after TKA Mistry et al.
concluded there was no difference in outcome as a result of
high-impact activities.
Contrarily, studies have demonstrated unfavorable results
with high levels of activity. Lavernia et al116 conducted a
study examining autopsy-retrieved specimens after TKA, and
observed a positive correlation between activity level, poly-
ethylene component wear rate, and length of prosthesis
implantation. Another study by Mintz et al117 evaluated tibial
polyethylene in 33 patients after TKA, where component
failure was more notably observed in younger patients.
They suggested this association was likely due to patient
activity level.
The amount of experience a patient has in a recreational
activity is also important to consider during rehabilitation,
particularly for physically demanding activities with a risk for
injury, such as skiing, hiking, or horseback riding.110 It has
been proposed that individuals who are not regularly active,
and therefore inadequately prepared for sporting activity, are
at higher risk for athletic injury.118 Additionally, the knee
joint in a beginner may experience greater loads as compared
with someone who is at a more advanced level.111 In beginner
skiers, it was found that the knee joint forces were 7,463 N
during the steering phase while veteran skiers experienced
considerably lesser knee joint forces of 2,775 N.
In summary, rehabilitation in younger, more active
patients is often aimed toward resuming athletic participa-
tion. While patients should be encouraged to remain physi-
cally active following TKA, they should initially be limited to
lower-impact activities of shorter duration. Patients should
focus on achieving fundamental functions of their lower
extremities before advancing, in an effort to decrease chances
of injury. Moreover, physicians should account for patients’
baseline and expected postoperative activity levels when
planning a rehabilitation exercise program.
Recommendations
A major objective of this review was to propose a set of
guidelines for patient return to activity or sport after TKA. It
should be noted that previous authors have attempted to
provide suggestions, as well. A report by Pozzi et al21
reviewed the current literature and highlighted the benefit
of supervised therapy sessions using combined modalities
that progress in intensity based on the patient’s progress.
The strengths of this review lie in their inclusion of several
rehabilitative modalities such as strengthening, aquatic
therapy, balance training, and the importance of clinical
environment. In another review, Westby et al22 examined
the available literature for therapy after TKA and outlined
the advantages of structured, supervised rehabilitation.
Strengths of this report are that they included survey
results from two expert panels to determine the best
practices, and that they provide recommendations of out-
come measures to routinely assess (functional, satisfaction,
quality of life, etc.). However, both reviews are limited in
that they do not encompass all available rehabilitative
modalities, and they do not discuss recommendations for
specific “subsets” of growing populations that warrant
The Journal of Knee Surgery Vol. 29 No. 3/2016
consideration. Our review aimed to address both of
these issues.
Based on the evidence examined, the optimal rehabilita-
tion protocol should include several crucial components.
Patients should engage in strengthening and functional
exercises that progress as clinical milestones are met over
the first 8 weeks after TKA. Careful early mobilization of the
patella in all directions is critical for optimal ROM. Rehabili-
tation is encouraged to begin as soon as the first POD.
Strengthening programs can begin as closed-chain quadri-
ceps exercises with supplemental weight added, and eventu-
ally progress to include eccentric and isokinetic exercises that
are performed in concentric and eccentric modes throughout
the entire knee ROM. Goals should include an emphasis on
improvement of functional independence and mobility, nor-
malization of gait mechanics, pain reduction, and attainment
of early ROM.21,22,33 We agree with the research by Ebert
et al119 that suggests active knee flexion of 80 degrees at the
initial outpatient visit (1–2 weeks post-TKA) is strongly
correlated with active knee flexion of 110 degrees at 7 to
8 weeks after TKA. The achievement of 110 degrees of knee
Downloaded by: Universite Laval. Copyrighted material.
flexion has been shown to provide a satisfactory function for
most patients to complete most activities of daily living. This
knee flexion guideline may allow for the administration of a
more focused and individualized rehabilitation. As a result,
patients may gain a better understanding of realistic goals of
progression throughout the early stages of therapy, while
practitioners may be able to simultaneously identify patients
at high risk for poor long-term outcomes who may benefit
from additional intervention. Additionally, the SAFTE proto-
col should be considered as a part of the patients’ physical
therapy regimen.24 Balance training may also be supple-
mented into therapy sessions in an effort to restore joint
proprioception and postural control.50 Providers can consider
recommending aquatic therapy to engage patient participa-
tion while regaining strength and relieving pain.40 Rehabili-
tation sessions should be initially supervised and eventually
transform into the patient’s responsibility at home. Regular
guidance and progression should be provided to ensure
proper utilization of home exercises.
Cryopneumatic therapy via intermittent ice pack and
compression should be provided at the end of each therapy
session due to its positive effects on inflammation, edema,
and pain relief.60 Patients expressing concern with excessive
narcotic usage can be offered an automatic cryopneumatic
device rather than ice and static compression. We recom-
mend the use of sling therapy over CPM, as it provides similar,
if not better results and is more cost-effective.55 The use of
NMES in addition to progressive strengthening exercises has
shown promising results and should be provided to attenuate
the early loss of quadriceps strength after TKA.25,79 The ability
of NMES to recruit of additional type II (fast-twitch) muscle
fibers enables greater force generation, assisting in rehabili-
tation and functional performance. TENS is not recommended
as a solo therapy, however, we recommend its use as an
adjunct to other pain management modalities. Adequate
pain control can help facilitate early patient participation in
recovery, which may ultimately lead to better functional

outcomes. Preliminary studies92,99,100 have demonstrated
promising results on the use of instrument-assisted soft-
tissue therapy for several chronic orthopedic diseases, how-
ever, further prospective evaluations are needed to assess its
utility as a rehabilitation technique for knee stiffness follow-
ing TKA.
All physicians should encourage healthy forms of weight
loss in obese patients (BMI > 30) to reduce risk of osteoar-
thritis and its progression. Regardless of preoperative or
postoperative status, providers have a responsibility to coun-
sel patients to pursue a sustainable, healthy, and active
lifestyle.106
In regards to activity, emphasis should be placed on
fundamental rehabilitative modalities before resumption of
higher demand activity. Enthusiastic patients may be eager to
return to activity, but should be educated on the risks and
precautions before proceeding. Low-impact activities such as
walking, swimming, and stationary bicycling can be encour-
aged, but patients should consult with their surgeons before
engaging in higher impact activities.
Conclusion
In conclusion, recovery of strength and ROM after TKA can be
achieved by a combination of modalities. Not all forms of
rehabilitation may apply to every patient who undergoes
TKA, given the potential presence of additional comorbidities.
The importance of joint strengthening and gradual introduc-
tion to a more active lifestyle cannot be overemphasized.
Proper instruction and commitment to rehabilitation can
potentially help patients achieve, or even surpass, their
preoperative activity levels.
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 Appendix 1 Summary of studies examining post-TKA rehabilitation

Author, year Study group Therapy type Start of program End of program Primary measures Secondary Final
measures follow-up
Physical therapy Petterson et al, 2009 Intervention Progressive strengthening 3–4 wks postoperative 6 wks Quad strength and acti- SF-36, KOS ADLS, 12 mo
vation, TUG, SCT, 6MW knee AROM, knee
Control Standard rehabilitation N/A N/A
pain
Bade and Stevens- Intervention HI Upon hospital discharge 25 wks Pain, ROM, functional N/A 12 mo
Lapsley, 2011 performance, quadri-
Control LI 8 wks
ceps strength and
activation
Moffet et al, 2004 Intervention Intensive functional exer- 2 mo postoperatively 6–8 wks 6MW Total WOMAC, WO- 12 mo
cises þ home exercises MAC Pain
Control Usual care N/A N/A
Evgeniadis et al, Intervention A Core and upper extremity 3 wks preoperatively 12–14 d Iowa level of assistance N/A 14 wks
2008 exercises þ standard inpa- postoperatively scale, AROM
tient rehab
Intervention B Lower extremity home su- At discharge 8 wks
pervised þ standard inpa- postoperatively
tient rehab
Control Standard inpatient rehab N/A 12–14 d
postoperatively
McGrath et al, 2009 Primary TKA Custom knee device þ stan- 4–8 wks postoperatively Mean 8 wks Extension ROM, KSS N/A Mean
dard PT regimen pain/function scores 18 mo
Revision TKA
Aquatic therapy Valtonen et al, 2010 Intervention Progressive aquatic Mean 10 mo 12 wks Walking speed, SCT, N/A N/A
resistance postoperatively knee flexor/extensor
power, mean thigh
Control No intervention
muscle CSA, WOMAC
Valtonen et al, 2011 Intervention Progressive aquatic Mean 10 mo 12 wks Walking speed, SCT, N/A 12 mo
resistance postoperatively knee flexor/extensor
power, mean thigh
Control No intervention
muscle CSA, WOMAC
Harmer et al, 2009 Intervention Water-based exercise 2 wks postoperatively 6 wks WOMAC, knee ROM, N/A 26 wks
program 6MW, stair climbing
power
Control Land-based exercise program
Balance training Piva et al, 2010 Intervention Functional training þ bal- 2–4 mo postoperatively 6 wks WOMAC, LEFS Gait speed, single leg 6 mo
ance training balance
Control Functional training
Liao et al, 2013 Intervention Functional training þ bal- N/A 8 wks Timed 10 min walk, N/A 8 wks
ance training TUG, WOMAC

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Rehabilitative Guidelines after TKA

Control Functional training

Fung et al, 2012 Intervention Standard physiotherapy Mean 37 d Mean 54 d Pain, knee flexion, knee N/A N/A

Vol. 29
þ 15 min of video games
Control Standard physiotherapy
þ 15 min lower leg
strengthening
postoperatively extension, walking
speed, timed standing
Mean 46 d Mean 53 d
tasks, LEFS, patient
postoperatively
satisfaction

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(Continued)
213

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 214

Appendix 1 (Continued)

Author, year Study group Therapy type Start of program End of program Primary measures Secondary Final
measures follow-up
CPM Romness and Rand, Intervention PT þ CPM Immediate Mean 7.7 d Knee flexion at dis- N/A 1y
1988 postoperative charge, postoperative
Control PT þ bulky compression Mean 10.3 d
wound drainage, LoS
dressing
McInnes et al, 1992 Intervention CPM þ standard rehab Immediate 7 d for CPM Pain, active/passive Complications, LoS 6 wks

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postoperative knee ROM, swelling,
quadriceps strength
Control Standard rehab POD 1 N/A

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Pope et al, 1997 Intervention A CPM 0–40 degrees Immediate CPM removed after Mean flexion, functional N/A 12 mo
postoperative 48 h score, ROM, fixed flexion
Intervention B CPM 0–70 degrees
deformity, analgesic
Control Physiotherapy only POD 1 N/A usage

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Rehabilitative Guidelines after TKA

Maniar et al, 2012 Intervention A 1-d CPM Immediate POD 2 Pain, ROM, TUG, swell- N/A 3 mo
postoperative ing, WOMAC, SF-12,
Intervention B 3-d CPM POD 4
wound healing
Control No CPM POD 5
Joshi et al, 2015 Intervention CPM þ physiotherapy Immediate postopera- Until hospital AROM, complications, N/A 3 mo
tive for CPM; POD 1 discharge discharge disposition,
Control Physiotherapy
WOMAC
Mistry et al.

Mau-Moeller et al, Intervention Physiotherapy þ sling POD 2 1 d before discharge Passive knee flexion Active knee flexion 3 mo
2014 exercises ROM ROM, active/passive
knee extension ROM,
Control Physiotherapy þ CPM
static postural con-
trol, physical activity,
pain, LoS, SF-36, HSS,
WOMAC
Cold and compres- Levy and Marmar, Intervention Cold compressive dressings Immediate Postoperative day 14 Blood loss, change in N/A N/A
sive therapy 1993 postoperative hemoglobin, analgesic
Control Standard dressings
usage, total arc ROM
Su et al, 2012 Intervention Cryopneumatic device Immediate N/A ROM, 6MW, TUG, knee N/A 6 wks
postoperative girth, narcotic use,
Control Ice with static compression
satisfaction
Bech et al, 2015 Intervention Consistent cooling via mo- Immediate First 48 h Pain (NPRS) Nausea, vomiting, First 48 h
torized device postoperative postoperatively passive ROM, opioid postoperatively
use, patient satisfac-
Control Intermittent cooling
tion, patient
compliance
NMES Stevens-Lapsley et al, Intervention Standard rehab þ NMES Rehab on POD 1; NMES 6 wks Quadriceps strength, SF-36, WOMAC 12 mo
2012 on POD 2 hamstring strength,
6MW, SCT, TUG, exten-
Control Standard rehab POD 1 8 wks
sion active ROM
Avramidis et al, 2011 Intervention Physiotherapy þ NMES POD 2 6 wks 3-min walk test, SF-36, N/A 12 mo
KSS
Control Physiotherapy POD 1 N/A
Levine et al, 2013 Intervention Home ROM exercise þ NMES 14 d preoperative 60 d postoperative KSS pain/function, WO- N/A 6 mo
MAC, TUG
Control Therapist-managed ROM ex- N/A N/A
ercise þ strengthening
exercises

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 Appendix 1 (Continued)

Author, year Study group Therapy type Start of program End of program Primary measures Secondary Final
measures follow-up
TENS Stabile and Mallory, Intervention A Placebo TENS þ IM Immediate POD 3 Analgesic usage N/A POD 3
1978 hydromorphone postoperative
Intervention B Actual TENS þ IM
hydromorphone
Control IM hydromorphone
Rakel et al, 2014 Intervention A TENS Immediate 6 wks Pain during ROM and Pain intensity at rest, 6 wks
postoperative walking hyperalgesia,
Intervention B Placebo TENS 6 wks
function
Control Standard of care (pharmaco- N/A
logical analgesia only)
Breit et al, 2004 Intervention A PCA þ TENS Immediate First 24 h Use of sedation, spinal N/A First 24 h
postoperative postoperatively anesthesia, morphine; postoperatively
Intervention B PCA þ placebo TENS
VAS
Control PCA
Angulo et al, 1990 Intervention A Sensory threshold Immediate POD 3 VAS, pain relief, hospital N/A Either POD 3 or
TENS þ CPM postoperative stay, knee flexion arc, discharge from
narcotic usage hospital
Intervention B Subthreshold TENS þ CPM
Control CPM only

Abbreviations: 6MW, 6-min walk; ADLS, activities of daily living; AROM, active range of motion; CPM, continuous passive motion; CSA, cross-sectional area; HI, high intensity; IM, intramuscular; KOS, Knee Outcome
Survey ; KSS, knee society score; LEFS, Lower Extremity Functional Scale; LI, low intensity; LoS, length of stay; N/A, not applicable; NMES, neuromuscular electrical stimulation; POD, postoperative day; PT, physical
training; rehab, rehabilitation; ROM, range of motion; SCT, stair-climb test; SF-12, short form-12; SF-36, short form-36; TENS, transcutaneous electrical nerve stimulation; TKA, total knee arthroplasty; TUG, timed-up-
and-go test; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Arthritis Index.

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Appendix 2 Physical therapy guidelines for total knee arthroplasty. (Reprinted with permission from authors and AlterG, Inc., Fremont, CA.)

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 Rehabilitative Guidelines after TKA Mistry et al. 217

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Appendix 2 (Continued )

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