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The Effect of Early Progressive Resistive Exercise Therapy on Balance

Control of Patients With Total Knee Arthroplasty: A Randomized
Controlled Trial

Article  in  Topics in Geriatric Rehabilitation · October 2017

DOI: 10.1097/TGR.0000000000000165

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 Topics in Geriatric Rehabilitation • Volume 33, Number 4, 286-294 • Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/TGR.0000000000000165
The Effect of Early Progressive Resistive
Exercise Therapy on Balance Control of
Patients With Total Knee Arthroplasty
A Randomized Controlled Trial
Razieh Yousefian Molla; Heydar Sadeghi, PhD; Amir Hossein Kahlaee, PhD
Background and Purpose: Although total knee arthroplasty
(TKA) is a common treatment for severe osteoarthritis, high
risks of fall and balance loss are the main complications of
this procedure. While multiple rehabilitation protocols have
been suggested for TKA, efficacy of early resistive exercise
therapy aimed at improving balance has not yet been
thoroughly investigated.
Methods: In this double-blind randomized controlled trial
study, 40 patients with severe osteoarthritis, sampled by a
simple convenient method, were randomly assigned into
either “control” group or “early resistive exercise” group.
After TKA surgery, both groups attended a routine rehabilita-
tion program while the experimental group received extra
early resistive exercises. Static, semidynamic, and dynamic
balance were assessed by the Sharpened Romberg (SRBT),
Star Excursion (SEBT), and Berg (BBT) balance tests prior to
surgery, after the rehabilitation process (seventh week), and
at a 2-week later follow-up time (ninth week).
K nee osteoarthritis (OA) is a progressive degenera-
tive disease and a leading cause of disability among
the elderly.1,2 Prevalence of knee OA is higher in
women and increases with age.1 Total knee arthroplasty
(TKA) is a commonly accepted surgical procedure recom-
mended for severe OA characterized by radiographic evi-
dence of joint damage, moderate to severe persistent pain,
and clinically significant functional limitations affecting the
quality of life when conservative treatments such as
Author Affiliations: Department of Sport Biomechanics, Faculty of Physical
Education and Sport Sciences, Islamic Azad University of Central Tehran
Branch, Tehran, Iran (Ms Yousefian Molla and Dr Sadeghi); and Rofeideh
Rehabilitation Hospital and Department of Physical Therapy, University of
Social Welfare and Rehabilitation Sciences, Tehran, Iran (Dr Kahlaee).
This study was partly supported by Faculty of Physical Education and
Sports Biomechanics, IAU.
The authors have disclosed that they have no significant relationships
with, or financial interest in, any commercial companies pertaining to this
article.
Correspondence: Amir Hossein Kahlaee, PhD, Department of Physical
Therapy, University of Social Welfare and Rehabilitation Sciences, Koodakyar St,
Daneshjoo Blvd, Evin, Tehran, Iran (amir_h_k@yahoo.com).
286 www.topicsingeriatricrehabilitation.com
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Results: At the end of the seventh and ninth weeks, in both
groups all 3 balance scores were significantly enhanced
comparing the baseline scores (P < .001). The experimental
group had significantly higher scores than the control group
in SRBT, SEBT, and BBT after the intervention and at the
follow-up time (P < .001).
Discussion and Conclusions: The findings of this study
showed that rehabilitation following TKA is accompanied by
balance (static, semidynamic, and dynamic) improvement,
and this improvement is greater among patients participating
in an early resistive exercise regimen. Early progressive
resistive exercise in addition to routine physical therapy may
lead to better balance performance than routine physical
therapy and might be incorporated into the postoperative
physical therapy of these patients. Further studies with longer
follow-up periods are needed to confirm these results.
Key Words: balance, early resistive exercise, rehabilitation,
total knee arthroplasty
nonsteroidal anti-inflammatory drugs, physical therapy, and
intra-articular corticosteroid injections fail.1 Rehabilitation
following TKA is crucial to the success of the surgery. Reha-
bilitation emphasizes exercise programs to improve range
of motion, muscle flexibility, strength, endurance, and walk-
ing skills.3 Most studies recommend that rehabilitation be
initiated immediately after discharge from the hospital.4
Falling is a serious problem with significant economic,
personal, and social costs among the elderly with multiple
risk factors.5 Balance loss has shown to be an important
predictor of falls in this population6,7 and is, therefore, an
important issue to be addressed after TKA to prevent falls
and provide confidence to perform activities of daily liv-
ing (ADLs) in a safe manner. Balance is also a crucial pre-
dictive factor for functional recovery after primary TKA.
However, studies have reported diminished postural and
neuromuscular control, as well as balance performance,8
and increased risk of falling following TKA compared with
healthy age-matched individuals.9 Balance is the product
of integration of multiple sensory inputs (visual, vestibular,
and proprioceptive systems), central processing of these
October–December 2017
data, and neuromuscular responses, and is defined as
the ability to maintain postural stability during quiet and
perturbed standing and voluntary movement.10 Balance
defined as the ability to maintain the center of mass within
the body’s base of support11,12 can be assessed during static
postures or dynamic tasks. The ability to keep the center
of mass projection within base of support in a stationary
state or within a moving context is referred to as static
and dynamic balance, respectively.13,14 Altered proprio-
ception will increase the risk of falls by adversely affecting
the afferent information to the central-processing centers
responsible for motor command generation.15 Deficient
proprioception and reduced muscle strength have been
commonly reported with the aging process, with the pres-
ence of knee OA and after TKA and are both shown to
interfere with ADL performance and subsequently reduce
quality of life.1 Reduced gait speed, difficulty in negotiat-
ing up and downstairs, balance loss, and risk of falling may
persist as long-term complications of the TKA surgery in
addition to postoperation muscular inhibition sequelae.16
Hence, physical therapy is necessary to mitigate the func-
tional limitations following TKA. Since proprioception
modulates muscular activity, affected knee joint mecha-
noreceptors may induce muscle weakness.17 Changes in
the knee joint proprioceptor function may contribute to
altered balance control during both static and dynamic
tasks.18 Quadriceps (QC) muscle weakness after TKA is
also attributed to failure of voluntary muscle activation (ie,
muscle inhibition).19 One month after TKA, QC strength
decreases to 60% of preoperative level.20 Lower extremity
strengthening exercises can reduce functional limitations
such as balance in the elderly.21 Based on the association
of knee extensor muscles strength and dynamic stability
in the elderly population, strengthening exercises of these
muscles have been recommended for fall prevention dur-
ing ADLs.22 Stensdotter et al23 found QC muscle strength to
be correlated with the postural control capabilities of the
subjects with TKA and thus recommended QC strength-
ening to be included in TKA postoperative rehabilitation.
Lim et al24 have shown that strengthening the QC muscle
after TKA via a progressive resistive regimen will enhance
balance control.
Early accelerated rehabilitation has received increasing
attention in the last decade. Increased range of motion,
muscle strength, functional performance, and quality of
life have been the main outcomes of early rehabilitation
after TKA.25 Although multiple studies have investigated
different rehabilitation protocols after TKA, there are few
comparing early progressive resistive exercises with more
conventional protocols. Only 1 aspect of balance has been
assessed as the outcome measure of most studies on TKA,
but to our knowledge, no study has compared the effect of
early resistive exercise therapy after TKA on the different
aspects of balance.4,26,27
Topics in Geriatric Rehabilitation
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The aims of this study were thus to investigate whether
an early progressive strengthening exercise program could
improve static, dynamic, and semidynamic balance com-
pared with routine physical therapy in patients with TKA.
We hypothesized that (i) a 6-week rehabilitation program
after TKA would improve balance and (ii) addition of early
progressive resistive exercise to routine physical therapy
after TKA would yield greater improvement in balance.
METHODS
Study design and randomization
This investigation was a double-blind randomized con-
trolled trial study examining the effect of early progressive
resistive exercise therapy on balance in patients undergo-
ing TKA. Participants were allocated to the experimental or
control group in the order they were referred on a 1:1 ratio
until there were 20 female subjects in each group. In this
method, the first referred patient would fall into either
group by chance and the next one into the other group.
This would ensure avoidance of patient selection bias. The
orthopedic surgeon referring the patients was unaware of
allocation order. The patients were blinded as to what
group they were assigned.
Setting and participants
Forty female patients with severe primary knee OA (grade
4 on Kellgren/Lawrence classification system)28 were
recruited into this study. All these patients, sampled by
simple convenient method, were candidate for bilateral
TKA surgery and were referred from the orthopedic clinic
of Akhtar Hospital in Tehran during Spring to Fall 2013.
Because of higher rate of OA among women, only females
were included in this study.1 All subjects were informed
about the content of the study and volunteered to partici-
pate by signing the informed consent form approved by
the medical ethics committee of Shahid Beheshti Univer-
sity of Medical Sciences. The inclusion criteria were as fol-
lows: (1) age between 60 and 75 years, (2) primary knee
OA, (3) both knees candidate for TKA, and (4) fixed pros-
thesis used for surgery. The subjects were excluded if they
had a prior TKA surgery or any deformity in lower extrem-
ities other than in the knees or any neurological or non-
corrected visual deficit affecting their balance. The sam-
ple size was calculated on the basis of the variance of the
outcome measures and an extra amount to count for
probable dropouts. Patients not attending 100% of their
therapeutic sessions were also excluded from the study.
The initial evaluation of all subjects, including demo-
graphic data, anthropometric characteristics, Sharpened
Romberg (SRBT), Star Excursion (SEBT), and Berg (BBT)
Balance Tests (to evaluate static, semidynamic, and
dynamic balance, respectively),29-31 was performed 2 days
prior to surgery. All patients underwent TKA surgery by
www.topicsingeriatricrehabilitation.com 287
the same surgeon and technique using a fixed articular
surface prosthesis. While rehabilitation was started from
the first day after surgery, the balance scores were remeas-
ured after the rehabilitation process (7 weeks after sur-
gery) and at a follow-up stage (9 weeks after surgery). All
balance tests were scored by the first author who was una-
ware of the assignment of the subjects until the analysis
phase of the study while the allocation sequence and
assignment of the subjects were performed by the statisti-
cian who also performed the statistical analysis of the
study.
Intervention
The rehabilitation protocol (being the same for both
groups until the second week postoperation) was initiated
the day after surgery. The patients in both groups received
3 rehabilitation sessions a week for an hour per session and
for 6 weeks (all patients were discharged from hospital
within 3-4 days from the date of surgery).
Routine rehabilitation included edema and pain con-
trol, regaining range of motion, improving knee flexor and
extensor muscles strength performing isometric exercises
of thigh muscles, ambulation, and gait training.32 Thus, both
isometric and isotonic (nonresistive type) modes of exer-
cise were included in the routine physical therapy program
for knee flexor and extensor muscle groups. All patients
received instruction regarding the appropriate use of assis-
tive devices for ambulation. Continuous passive motion
was started on the first postoperative day for the range of
0° to 60° being increased as tolerated.33 The rehabilitation
program of the 2 groups became differentiated during the
second week of the outpatient rehabilitation protocol. The
control group performed both open kinetic chain (non–
weight-bearing) and closed kinetic chain (weight-bearing)
exercises initially with 2 sets of 10 repetitions, later pro-
gressed to 3 sets of 10 repetitions. Strengthening exer-
cises consisted of QC isometric contractions, seated knee
extensions (nonresistive), straight leg raises, side-lying
hip abduction, and standing hamstring curls. Body weight
exercises consisted of standing terminal knee extensions,
single-limb stance, and wall slides. Since closed kinetic
chain exercises targeting the knee joint muscles have been
proposed to be crucial to balance control improvement
after TKA,23,34 the experimental group received progres-
sive, resistive exercises of knee extensor muscles in addi-
tion to the routine rehabilitation program. The isotonic
resistive exercises were as follows: (1) stationary bicycling
with minimum tension for 5 minutes with weekly incre-
ments in duration up to 30 minutes: resistance to the ped-
als was increased as tolerated by the patient; (2) getting up
and down the stairs: the exercise would be initiated with
stairs as high as 2 to 4 in and progressed to higher stairs
(up to 6-8 in) with strength improvement during the reha-
bilitation phase of the study; and (3) weight-resisted knee
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flexion and extension. Weights were increased to maintain
a 10-repetition maximum targeted intensity level; the maxi-
mum weight utilized for any strengthening exercise was a
4.5-kg ankle weight. Duration of the cycling exercise, height
of the stairs, and amount of weight resistance were gradu-
ally increased in a weekly manner and determined by the
patients’ tolerance causing no persisting (lasting for more
than 1 hour) pain and swelling.35 The lower extremity mus-
cles (especially QC) have to overcome gravity force as large
as whole body weight to accomplish the transfer phase of
the stair-climbing task. Descending stairs also needs eccen-
tric activation of the hip and knee extensor muscles to
control body mass acceleration in the sagittal plane. Stairs
ascent/descent exercise was thus considered as a strength-
ening exercise due to the aforementioned physical require-
ments. Stationary cycling also requires alternating hip and
knee flexor and extensor muscles activation proportional
to the resistance applied through the pedals. The rationale
for external resistance adjustment was patient tolerance as
recommended by the literature to avoid symptom exacer-
bation.31,33 The main difference of the administered rehabil-
itation protocols lies in the progressive and resistive nature
of that in the experimental group. Both protocols included
isotonic exercises but a more intense, progressive regimen
was designed for the experimental group participants.
Attendance of the participants to the rehabilitation pro-
gram was tracked. Not completing the protocol would lead
to the exclusion of the participant from the study. None of
the participants were enrolled in any special physical activ-
ity other than usual ADL.
Outcome measures
Participants’ static and dynamic balances were evaluated
by SRBT, SEBT, and BBT within 1 week prior to surgery
(preoperation) and at the end of the seventh (postop-
eration) and ninth weeks (follow-up) after the surgery
for all patients. The tests performance order was rand-
omized to minimize learning effect. In the SRBT, the
patients were asked to hold the heel-to-toe standing
position with the dominant foot behind the nondomi-
nant foot with open eyes. Time recording was started
after the participant had assumed the proper position.
The test would be stopped if the patient failed to hold
the test position, or if she reached the maximum balance
time set as 60 seconds.36 Three trials were performed.
The longest balance time of the recorded trials was used
for data analysis. The SEBT has been introduced as a sim-
ple, reliable, and cost-effective alternative for instrumen-
tal devices to assess semidynamic balance.35 The SEBT is
a functional test that incorporates a single-leg stance on
1 leg while trying to reach as far as possible with the
opposite leg. The patients stood in a square at the center
of the grid with 8 lines extending from the center at
45° increments. The aim was to reach as far along each
October–December 2017
direction as possible to touch the furthest point on the
line while avoiding using the reach leg for support. The
patients would then return to the center of the grid on
both feet while maintaining balance.37 Each patient per-
formed 3 reaches (trials) in each of the 8 directions. The
average of the maximum reach distance in each of the 8
directions was considered for analysis. (A farther dis-
tance reached indicates better semidynamic postural
control.) (Figure 1). The BBT assessment consists of 14
subtests evaluating balance during different sitting and
standing postures and dynamic transfers between these
postures. Each task was scored on a 5-point scale (0-4).
The score “0” indicates the lowest and “4” the highest
level of function. Maximum total score for this test is 56.
Scores below 45 indicate that balance is limited, with an
increased risk for falls.38 The reliability of the balance
tests measurements using intraclass correlation coeffi-
cient statistical test was found to range between 0.73 and
0.94, indicating a high to very high level of reliability39 in
the methodological phase of the study.
Statistical analyses
Descriptive statistics (mean and standard deviation) were
used to describe all study variables. The normality of the
distribution of the data was tested by the Kolmogorov-
Smirnov (K-S) test for all study variables before the main
statistical analysis. Three separate time (3) × group (2)
repeated measures analyses of variance were performed to
determine the main and interactive effects for each
dependent variable (SRBT, SEBT, and BBT). The within-
group factor was time (with 3 levels: pre- and postinterven-
tion and follow-up) and the between-group factor was
intervention (with 2 levels: routine physical therapy vs
Figure 1. Schematic representation of the SEBT test setup.
The participants’ stance leg has been demonstrated in the
center of the grid, while the reach leg tried to touch the
furthest distance on each of the projecting lines.
Topics in Geriatric Rehabilitation
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early resistive exercises in addition to routine physical ther-
apy). Post hoc analyses with a Bonferroni correction were
performed for pairwise comparisons. The student inde-
pendent samples t test was used to analyze the differences
between the SRBT, SEBT, and BBT in the 2 groups when
the group main effect was found to be significant. Effect
sizes (Cohen d) were calculated for the dependent varia-
bles at postintervention and follow-up times. The magni-
tude of the effect was classified as small (0.20-0.49),
medium (0.50-0.79) or large (0.8) according to Cohen
method.40 Statistical significance level was set at P < .05.
Statistical analyses were performed using the Statistical
Package for the Social Sciences (SPSS) software (version
20, SPSS Inc, Chicago, Illinois). Since there were no drop-
outs or missing data, all analyses were performed on all
40 participants (20 in each group).
RESULTS
Participant characteristics
Forty female patients with severe OA scheduled for pri-
mary TKA took part in this clinical trial. The analysis of the
demographic characteristics revealed no significant differ-
ence between the 2 groups of patients (Table 1). The result
of the K-S test was indicative of normal distribution of the
data of the balance scores in both groups. No patients in
either group experienced a musculoskeletal injury during
the rehabilitation program. There was no surgery failure in
either group according to the surgeon’s assessment at
ninth week after surgery. Periprosthetic loosening, frac-
ture, and infection are common surgery failures that need
revision.41
Balance outcome
Repeated measures analysis of variance test results showed
that the interaction of the 2 independent variables (group
× time) was statistically significant for SRBT (F = 75.68, P
< .001), SEBT (F = 12.77, P = .001), and BBT (F = 10.42,
P = .003) (Figure 2).
The group (F = 18.77, P < .001) and time (F = 325.67,
P < .001) variables had significant main effects on the
scores of the SRBT. Post hoc analyses indicated that in both
TABLE 1 Comparison of the Demographic
Characteristics of the 2 Groups
Experimental
Mean (SD), Control Mean
Group Variable n = 20 (SD), n = 20 P
Age, y 69.4 (5.7) 67.9 (5.3) .322
BMI, kg/m 2
30.2 (5.2) 28.3 (5.3) .216
Pain duration, y 5.6 (5.1) 5.2 (4.5) .398
www.topicsingeriatricrehabilitation.com 289
Figure 2. Interactive plots of the (A) SRBT (seconds), (B) SEBT (cm), and (C) BBT score responses to the 2 intervention
protocols at the preoperation, postoperation, and follow-up time intervals.
groups, SRBT scores were significantly increased from the
preoperation to the postoperation and from postopera-
tion to the follow-up time. The results revealed significant
main effects for group (F = 12.07, P < .001) and time (F =
211.64, P < .001) variables on the SEBT scores. Just as the
SRBT, the scores in SEBT test were significantly increased
with progression of time in both groups. The main effects
of the independent variables were also statistically signifi-
cant in both groups on the BBT scores (F = 5.73, P = .285
for group and F = 132.76, P < .001 for time). Patients in
both groups had higher balance scores after the interven-
tions. The effect size (d) for outcome measures was greater
for the experimental group at the seventh week after inter-
vention in the SRBT (d = 2.2), SEBT (d = 1.3), and BBT
(d = 1.9) than for the control group (d = 1.2, 0.9, and
1.5), respectively. The SRBT (d = 2.8) and BBT (d = 2.3)
showed greater improvement in the experimental group
after 2-week follow-up than those in the control group (d =
1.9 and 2.0), respectively. Results are presented in Table 2.
The results also indicated that while the groups
were statistically not different according to the balance
scores at baseline, the experimental group had higher
scores in SRBT (P < .001), SEBT (P < .001), and BBT
(P = .002) after the 7 weeks of intervention and at
the 9-week follow-up time (P < .001, .005, and .001,
respectively) (Table 3).
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DISCUSSION
The main purpose of this study was to investigate the effect
of addition of early progressive resistive exercises to rou-
tine physical therapy on balance performance of elderly
women after TKA. The findings of this study showed that
TKA surgery, followed by routine rehabilitation, with and
without early resistive exercise regimen, is accompanied by
static, semidynamic, and dynamic balance improvement.
The findings are in line with those of recent studies investi-
gating the effect of rehabilitation on balance in knee OA
patients. Liao et al42 showed a positive effect of balance
training in addition to functional rehabilitation, initiated
within 2 months after hospital discharge, on balance,
mobility, and function in patients with TKA. Silva et al43 in a
systematic review reported that therapeutic exercise, espe-
cially QC strength training, would improve balance of
women with knee OA.
Since balance control incorporates both reliable sensory
information and proper motor command necessitating
adequate muscular force,11,44 improvement in either com-
ponents (sensory and motor) may enhance balance perfor-
mance. Deficits in knee joint proprioception and insufficient
extensor muscles strength have been associated with knee
OA and TKA and may both lead to balance loss.45,46 Closed
kinetic chain exercises have been traditionally considered
to enhance proprioceptive performance by stimulating the
October–December 2017
 TABLE 2 The Effects of Interventions on the 3 Balance Scores in Each of the Experimental
and Control Groups
Group
Experiment Control
Test Time Interval Mean Difference (SD) P Mean Difference (SD) P
SRBT, s Pre-Post 18.6 (0.9) <.001a 5.5 (0.9) <.001a
a
Post-Follow 3.9 (1.0) .022 3.0 (0.6) .030a
Pre-Follow 22.5 (3.1) <.001a 8.5 (1.0) <.001a
SEBT, cm Pre-Post 19.6 (1.4) <.001a 9.2 (1.4) <.001a
Post-Follow 4.3 (0.7) .004a 8.5 (0.7) .001a
Pre-Follow 23.9 (1.9) <.001a 17.6 (1.9) <.001a
BBT (score) Pre-Post 10.9 (0.9) <.001a 5.6 (0.8) <.001a
Post-Follow 1.7 (0.4) .030a 1.9 (0.5) .001a
Pre-Follow 12.6 (1.2) <.001a 7.5 (1.1) <.001a
a
Significant difference.

intra- and extra-articular mechanoreceptors47 and simulta-
neously increase muscular strength.48 Further studies inves-
tigating the direct influence of such exercise programs on
muscular power and joint position and force senses are
necessary to elucidate the underlying mechanisms for the
observed improvement in balance.
Many studies have investigated static balance in TKA
patients, but static balance assessment may not be sensitive
enough to detect all motor control deficits.49 The results of
our study revealed that more profound improvement in
static, semidynamic, and dynamic balance might be elicited
when progressive resistive exercise is added to routine
physical therapy as early as the second week postoperation.
One probable mechanism that may explain the resistive
isotonic exercise–induced improvements in balance is the
enhancement of muscle strength and endurance. Muscle
weakness, in particular, QC weakness, has been proposed
as one of the main contributors to limited balance com-
monly observed in older women with knee OA or TKA.46
Several studies have reported that OA has a negative effect
on strength and endurance of QC.50 The inhibitory effect of
pain, selective atrophy of type II muscle fibers, decreased

TABLE 3 Between-Groups Comparison of the 3 Balance Scores at Each of the 3 Stages of the
Study
Group
Test Time Experiment (Mean ± SD) Control (Mean ± SD) P
SRBT Preoperation 24.3 ± 7.9 21.1 ± 4.2 .276
Postoperation 42.9 ± 8.5 26.6 ± 4.3 <.001a
Follow-up 46.8 ± 7.8 29.6 ± 4.6 <.001a
SEBT Preoperation 40.9 ± 13.5 36.6 ± 9.6 .232
Postoperation 60.5 ± 14.9 45.8 ± 17.8 <.001a
Follow-up 64.8 ± 16.5 54.3 ± 11.6 .005a
BBT Preoperation 39.1 ± 6.9 38.3 ± 4.1 .758
Postoperation 50.0 ± 4.2 43.9 ± 2.3 .002a
Follow-up 51.7 ± 3.2 45.8 ± 3.1 .001a
a
Significant difference.

Topics in Geriatric Rehabilitation www.topicsingeriatricrehabilitation.com 291

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voluntary activation, and a deficit in protective reflexes of
QC due to OA may all lead to inhibition and weakness in this
muscle.46 Although muscle strength is not directly measured
in the present study, previous studies have shown lower
baseline muscle strength among women with OA46 and TKA
patients.51 Ciolac and Greve52 have shown that muscular
strength will significantly increase after a 13-week resistance
training program in women with OA and TKA. Quadriceps
muscle power enhancement has been proposed to be the
primary driver of such improvements in studies measuring
the muscular force production capacity.35 Participants in
our experimental group received more intense exercises
according to the external resistance applied. This may have
logically resulted in more strength improvement in the tar-
geted muscles which are also involved in balance control.
Closed kinetic chain exercises such as stepping may also
affect the sensory component of balance control by stimu-
lating the proprioceptive system.53 Better balance perfor-
mance in the experimental group might thus be attributed
to the greater increase in volume of their exercise, leading
to greater strength improvement (although not directly
measured in this study) and stimulation of the propriocep-
tive system since no balance-specific exercise was admin-
istered in either group. Previous studies have proven the
efficacy of exercise therapy regimens similar to the one uti-
lized in our study in QC muscle strengthening and balance
improvement after TKA,23,24,34 but not directly measuring
this variable remains a limitation to our study.
There is no definite agreement on the time of initia-
tion of isotonic resistive exercises necessary to enhance
muscular strength and thereupon body balance. Different
protocols have suggested a wide range of the 3rd to the
12th week after surgery as the proper time to start these
type of exercises.54 Since falling and balance loss are within
major concerns in OA patients and those undergone TKA
specially within the few days after the surgery,16 it seems
vital and worth exploring the most effective rehabilitation
protocol, yielding most possible balance improvement
in the shortest time period. Early progression of resis-
tive exercises is also beneficial by reducing the length of
the rehabilitation process. Lower limb muscles (QC, in
particular) strength could be crucial to functional per-
formance. Progressive resistive exercise may thus affect
physical functions such as ADL and health-related quality
of life by decreasing functional limitations such as balance
loss. Early initiation of progressive resistive exercise after
TKA may delay or prevent functional decline and depen-
dency associated with aging. One month after TKA, QC
strength decreases over half of its baseline strength, which
is attributed to QC voluntary activation deficit.55 Decrease
in QC strength a year after TKA is highly related to muscle
atrophy due to impaired voluntary activation.56 Hence, a
rehabilitation program aimed at QC muscle activation
improvement shortly after TKA may decrease the long-term
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consequences of muscle atrophy, strength loss, and bal-
ance decline in these patients. Bade and Stevens-Lapsley35
reported that TKA patients undergoing a high-intensity
physical therapy regimen would demonstrate higher levels
of functional capabilities (including balance performance)
even 52 weeks after the surgery comparing those receiving
routine rehabilitation.
Balance loss is one of the main contributors to fall-
ing. Fear of falling and loss of confidence leading to self-
restricted activity levels, physical function, and social
interactions limitations are psychological consequences
of falls.57 Improvement in all aspects of balance control in
TKA in the presence of early resistive exercise therapy in
addition to routine physical therapy may have important
implications in fall prevention and its consequences in this
specific population. Additional longitudinal studies inves-
tigating the impact of these balance improvements on fall
risk are needed. Mistry et al33 in a recent systematic review
found lower limb resistance exercises and balance training
both effective in improving functional performance after
TKA surgery. Starting these exercise as late as in the 6th or
12th week after surgery will make the rehabilitation process
last even up to 26 weeks.58 This is so long and sometimes
even exhausting that many patients will not complete their
rehabilitation program and thus continue to show balance
control, gait, and ADL performance deficits.54 Rossi et al59
have shown the knee extensor muscles to be much weaker
than the preoperation condition even 60 days after TKA.
This emphasizes the need to accelerate the rehabilitation
process to avoid consequences of muscle weakness and
proprioceptive deficits. Making the length of the rehabili-
tation process short enough for the patients to afford the
costs, and also not to be so time consuming, may provide
more patients the opportunity to get the most out of physi-
cal therapy. This might reduce the risk of balance loss and
surgery failure. The rehabilitation program utilized in this
study took 6 weeks, which is much shorter than many oth-
ers. Early progression of the exercises in the experimental
protocol might reduce the need for long protocols by pre-
vention of muscular deconditioning and early compensa-
tion for surgery-related muscular inhibition.
The other finding of the current study was that in both
groups, balance continued to improve even 2 weeks after
cessation of the treatment sessions. Spontaneous recovery
of the patients is ruled out by the significant difference
between the 2 groups even at the follow-up time. This may
endorse the effective role of rehabilitation following TKA
and indicate that early resistive exercises might put the
patients in a better balance condition that is sustained even
2 weeks after completion of the rehabilitation program.
One concern on the early initiation of resistive exer-
cises might be the safety of the protocol. The patients in
this study were not followed longer than 2 months after
surgery and longer follow-ups are needed to ensure its
October–December 2017
safety, but it does not seem that this protocol may be harm-
ful to the patients. A noticeable percentage of TKA surgery
failures occurs within the first few months and no failure
or adverse effects, such as considerable pain or range of
motion loss or musculoskeletal injuries, were noted in any
of the patients. Although, to our knowledge, no study has
directly studied the safety and possible side effects of early
isotonic resistive exercises after TKA, yet similar studies on
total hip replacement have shown to be safe.60
Study limitation
The present study has several limitations that must be
addressed. First, caution must be taken in generalizing the
present results. The small number of women with bilateral
TKA studied may not fully represent the target population
of patients with knee OA and TKA. The QC strength was
not directly evaluated in our study, and it is thereby not
feasible to propose it as the cause of the observed improved
balance. All that might be claimed is that balance improve-
ment was accompanied by the physical therapy program
including exercises supposed to address QC strength after
TKA. Since performance of the balance tests was not feasi-
ble immediately postoperation and before initiation of the
physical therapy programs, it is not possible to isolate the
observed improvements from the rehabilitation protocols
and those caused by the surgical intervention. Another
limitation is the short-term follow-up. It would be worth
studying the long-term clinical effectiveness of early iso-
tonic resistive exercise in addition to routine physical ther-
apy on balance, fall prevalence, and fall-related events/inju-
ries as future research.
CONCLUSION
The findings of this study indicated that while routine reha-
bilitation programs effectively enhance different aspects of
balance control after TKA, early initiation of progressive
resistive exercises may accelerate the balance recovery pro-
cess. These types of exercises did not result in any muscu-
loskeletal injuries or surgery failure in this small group of
patients in the timescale of this study.
Follow-up of the participants to investigate the long-
term consequences of early resistive exercise therapy
besides routine physical therapy after TKA to assess ADL
function following TKA as it relates to balance is suggested
for future work.
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