Title: Is having prior joint replacements beneficial or not for patient's rate of recovery

status post total knee arthroplasty?

Author: Amber Clees, SPT

Research Advisor: Rochelle M. Kopka, PT, DPT, DHSc

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

Date (Febuary 8, 2023)

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at
Central Michigan University
In partial fulfillment of the requirements of the
Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

Rochelle Kopka, PT, DPT, DHSc

Date of Approval: 2/8/2023
Background and purpose
Total knee arthroplasty (TKA) is a common orthopedic surgery especially in the United
States having the highest incidence rate of knee arthroplasties worldwide with an estimated 235
procedures per 100,000 Americans1. Patients will typically go to orthopedic doctors with a chief
complaint of knee pain. The orthopedic doctor orders imaging and determines if the pain is due
to osteoarthritis (OA) in the knee. Knee osteoarthrosis is one of the leading causes of global
disability2. If the OA in the knee is significant enough, the orthopedic surgeon will recommend a
TKA for that patient to relieve their knee pain. TKA’s are known to be successful procedures to
alleviate pain from knee OA3. The orthopedic surgeons will then refer their patient’s status post
TKA to physical therapy to address deficits of range of motion (ROM), strength, gait
abnormalities, and pain reduction. Manual therapy is typically implemented into the patient’s
plan of care to address soft-tissue restrictions and pain reduction. It is frequently used in patients
with various musculoskeletal disorders for pain reduction and to improve ROM4. Joint
replacement surgeries are becoming more relevant whether it is a TKA or a total hip arthroplasty
(THA). There is lacking research regarding whether having multiple prior joint replacements
affects the rehabilitation of a new joint replacement. This study is to evaluate a patient with a
history of bilateral THAs and TKA and determine if his new TKA rehabilitation will be helped,
hindered, or not show much difference when compared to patients with their initial joint
replacement.

Case Description
Patient History and Review of Systems
At the time of the intervention, the patient was an 82-year-old male who was referred to
outpatient rehabilitation for physical therapy pre-operation evaluation for a left total knee
arthroplasty secondary to left knee osteoarthritis. Based on the chart review, his past medical
history included osteoarthritis, hypertension, hyperlipidemia, and chronic left shoulder rotator
cuff tear with surgical history including right knee arthroplasty, bilateral total hip arthroplasty,
and hernia repair. The patient’s medications consisted of amlodipine for the treatment of
hypertension, atorvastatin to lower cholesterol levels, and meloxicam for the treatment of
osteoarthritis. With the review of systems, the patient has no significant findings throughout
integument, cardiopulmonary, neuromuscular, or gastrointestinal, but presents with
musculoskeletal abnormalities including pain throughout his left knee. He rates his left knee pain
on the Visual Analog Scale as a 0/10 at rest in sitting, and a 6/10 with certain activities including
all weight-bearing activities and sit-to-stand transfers. He describes his left knee pain as a dull
ache with occasional sharp pain. The patient reports receiving injections in his left knee, having
physical therapy treatments, and resting for pain management. The patient has had imaging of his
left knee secondary to knee pain resulting in degenerative joint disease of his left knee. After
consultation with his orthopedic surgeon, they have decided that a total knee arthroplasty to his
left knee is appropriate at this time, it was scheduled for five days after our initial evaluation with
him. The patient is currently retired and enjoys reading, exercising, gardening, yard work, and
traveling to his second house in the upper peninsula for the Michigan winters. The patient is
currently living in a two-story house with his wife, but is able to live on the main level if
necessary. He has two steps to enter his house with a hand railing on the left. Within his

2
bathroom, he has a tub shower, walk-in shower with a built-in shower chair, and grab bars in the
shower. He has a two-wheeled walker and cane at home from previous joint replacement
surgeries. He is not currently using an assistive device for mobility in his house or the
community. He reports having good family support to help provide him care and transportation
following his left total knee arthroplasty. The patient’s primary goal for physical therapy is to
return him to his prior level of function with minimal to no left knee pain following his left total
knee arthroplasty.
Prior to preparing this report, consent was obtained from the patient to proceed. All
information contained in this case report meets the Health Insurance Portability Accountability
Act (HIPAA) requirements of the clinical agency for disclosure of protected health information.
This case report was completed under the direction of the Department of Physical Therapy and
with the oversight of the College of Graduate Studies at Central Michigan University.

Clinical Impression 1
The physical therapist and student physical therapist thought left knee osteoarthritis is an
appropriate diagnosis for the patient due to subjective reports. We suspected he would have
difficulties with functional mobility and with weight-bearing activities such as standing, walking,
and transfers such as sit-to-stands. We planned to measure the range of motion of his bilateral
knees, using a goniometer. Girth circumferences measurements of his left knee would also be
taken, using a tape measure, to have a baseline before surgery. Strength was measured by manual
muscle testing of his lower extremities. We would also observe him ambulating to assess his gait
and possible gait abnormalities. Most of our objective measurements were planned so we could
get a good assessment of the patient’s prior level of function before his left total knee
arthroplasty. It was determined this patient would be a good candidate for a case report due to his
history of multiple joint replacements. The goal of this case report was to determine if having
prior joint replacements would be beneficial or not for this patient's rate of recovery.

Examination
Range of motion. Range of motion measurements of the patient’s left knee were taken in supine
using positions and procedures provided by Reese.5 Active and passive range of motion
measurements were taken of his left and right knee. Measurements included knee flexion and
extension. Right knee active range of motion (AROM) was recorded as 0-130 degrees. Right
knee passive range of motion (PROM) was recorded as 0-133 degrees. Left knee AROM was
recorded as 0-114 degrees. Left knee PROM was recorded as 0-116 degrees. The patient
demonstrated decreased active and passive range of motion throughout the left knee when
compared to the right knee.

Strength testing. Lower extremity strength was assessed using Manual Muscle Testing position
and procedures provided by Reese.6 These tests were modified and taken with the patient seated.
Hip flexion, internal rotation, external rotation, abduction, knee flexion and extension, and ankle
dorsiflexion were taken on both left and right lower extremities. The patient demonstrated
limitations throughout bilateral lower extremities with manual muscle testing, specific
measurements are shown in Table 1.

3
Posture. The patient’s posture was assessed in standing. Upon visual inspection, the patient
presented with bilateral shoulders rounded forward, head forward, increased thoracic kyphosis,
and his left knee with an increased valgus position.

Pain. For an objective measurement of the patient’s left knee pain, the Visual Analog Scale
(VAS) was used. The VAS is a measurement instrument that shows a scale from 0 to 10 with
images of faces below that correlate with the pain level and asks the patient to choose a number
from 0 to 10 to best describe their level of pain. A score of 0 being the patient has no pain and a
score of 10 being the worst pain/need to go to the emergency room. The test-retest reliability was
found to have intraclass correlation coefficients (ICCs) between 0.95 and 0.98 which is
considered to represent excellent reliability. The VAS is a valid and reliable measure of chronic
and acute pain intensity.7 The patient reported a 0/10 of current, resting left knee pain, and
reported a 6/10 of left knee pain at its worse. His pain score was obtained at the start of treatment
and throughout each physical therapy session.

Outcome Measure. To objectively measure the patient’s functional status and progress of his left
lower extremity status post left TKA, we used the Lower Extremity Functional Scale (LEFS).
The LEFS is a patient-reported measure that’s examines the functional status of the patient’s
lower extremity.8 “The LEFS consists of 20 items, with scores ranging from 0 (extreme
difficulty/unable to perform activity) to 4 (no difficulty). The total score can be obtained by
summing the scores of the individual items. The maximum score of 80 indicates no functional
limitations and the minimum score of 0 indicates extreme limitations”.8 Research reported that
the LEFS has an excellent test-retest reliability with intraclass correlation coefficients ranging
between 0.85 and 0.99.8 Research found that the LEFS demonstrated the expected relationships
with measures assessing similar constructs (Pearson correlation coefficient values of greater than
0.7).8 After research, the minimal detectable change at the 90% confidence level for the LEFS
scores was estimated at 6 points and the minimal clinically important difference was 9 points in
patients with lower extremity musculoskeletal conditions.8 At the patient’s first treatment session
following his left TKA, his initial LEFS score was recorded as 34.7 points. This indicates
moderate difficulty with activities of daily living regarding lower extremity function following
his left TKA.

Clinical Impression 2
The patient presented with deficits in lower extremity strength, range of motion, and
increased pain which could be correlated to his diagnosis of left knee osteoarthritis. With
assessments in the initial examination, the patient was greatly limited by his left knee pain
causing a limited ability to perform activities of daily living and functional activities including
sit-to-stand transfers and ambulation. He also had limited functional mobility with reduced left
knee range of motion when compared to the right causing difficulty with transfers and stair
ambulation. The patient’s impairments have led him to receive a left total knee arthroplasty and
he demonstrates good rehabilitation potential due to his history of successful total joint
replacements and the patient’s motivation. This patient has many positive factors such as good
family support and he is motivated to participate in physical therapy and be compliant with
exercises on his home exercise program before and after his total knee replacement.

4
 After an assessment of the patient’s impairments and a discussion of goals, a plan of care
was made. The first physical therapy goal was for the patient to have an increased range of
motion of the left knee to 0-120 degrees or better and strength for lower extremities to be 4+/5 or
better for increased ability to perform functional tasks and mobility including obtaining a
comfortable sleeping position, doing household chores, ascending/descending steps to enter
home and ambulating without an assistive device. The second goal was for the patient to improve
mobility and strength to the prior level of function as evidenced in the Lower Extremity
Functional Scale of no less than 45. The third goal was that the patient will be independent with
their home exercise program for stretching, strengthening, decreasing pain, increasing functional
mobility and strength, and for the patient to self-manage and prevent exacerbation of pain and
symptoms. The patient’s stated goals were to improve strength, and range of motion, and
improve pain with functional transfers and ambulation. To meet the patient’s goals and address
his impairments, the patient was scheduled to participate in physical therapy 2-3 times a week for
up to 4-6 weeks with physical therapy treatments including therapeutic exercises, neuromuscular
re-education, manual therapy, patient education, gait training, therapeutic activities, and
modalities. The patient continues to be a good candidate for this case report due to his unique
presentation of a history of bilateral total hip replacements and right total knee replacement to
determine if this would help or hinder his recovery from a left total knee replacement.

Interventions
The patient participated in outpatient rehabilitation 2-3 times a week with each session lasting
about 45 minutes for a total of twelve physical therapy appointments. The interventions used to
address his impairments and work towards his goals included therapeutic exercises, manual
therapy, patient education, gait training, and therapeutic activities. The patient’s first physical
therapy treatment session was three days after his left total knee replacement surgery. The patient
ambulated into the clinic status post left total knee replacement with a two-wheeled walker, ace
wrap covering his entire left lower extremity to hold PICO dressing and equipment in place, and
compression stocking below the knee on the right lower extremity. The patient’s presentation of
the left lower extremity changed throughout his physical therapy treatment sessions including the
removal of the ace wrap and PICO dressing at the patient’s second physical therapy treatment
session. At the patient’s seventh physical therapist appointment, the patient’s staples along the
incision of his left knee were removed and steri strips were placed along the incision.

Therapeutic exercise. A main concern and focus for the exercises status post the patient’s total
knee replacement included exercises to improve circulation, reduce the risk of blood clotting in
legs, and edema reduction. Initial exercises in a long sitting position included ankle pumps to
improve circulation, glute sets for gentle glute strengthening, and quad sets for gentle quadriceps
strengthening and to improve left knee extension range of motion. Exercises in supine included
left leg heel slides with a strap for passive knee range of motion into flexion, left leg heel slides
with active assisted range of motion provided by the physical therapist for active knee range of
motion, and straight leg raises to improve left lower extremity strength specifical hip flexion.
Exercises with the patient seated at the edge of the plinth included long arc quads active-assisted
range of motion provided by the physical therapist to improve left lower extremity strength
specifical quadriceps and left knee extension range of motion. The patient also rode the NuStep
for gentle left knee range of motion and strengthening. At each physical therapy treatment

5
session, the patient’s therapeutic exercises were progressed and addition of new exercises for
continued patient progression and improvement. Additional therapeutic exercises at the third
appointment included short arc quads in a long sitting position for quadriceps strengthening. At
the patient’s fourth appointment, the patient performed active range of motion with no assistance
provided by the physical therapist for long arc quad and short arc quad exercises. At the patient’s
seventh visit, he was introduced to standing hip abduction and hip extension to promote glute
strengthening and hamstring curls to promote hamstring strengthening in standing. The patient
progressed withstanding alternating toe taps onto a six-inch step to promote hip flexion
strengthening during the patient’s ninth visit.

Manual therapy.  Patellofemoral glides have been effective in increasing knee ROM secondary to
patellofemoral joint stiffness.9 On the patient’s fourth visit, gentle left patellar mobilizations were
performed by the physical therapist with the patient in a long sitting position with a small bolster
under his knees to optimal knee position for patellar mobilization. Maitland grade I-II joint
mobilizations were applied over 30 second increments for 2-3 sets with 1-2 oscillations per
second. Passive left knee range of motion into flexion and extension was performed by the
physical therapist with the patient seated at the edge of the plinth to help improve passive range
of motion of the patient’s left knee. Soft-tissue mobilization has been proven to improve tissue
extensibility and joint mobility.10 At the patient's eleventh visit, the physical therapist performed
gentle scar mobilization to the patient’s left knee to help mobilize the scar tissue present along
the patient’s scar and help prevent soft-tissue adhesions along the patient’s scar.

Gait training.  At the patient's fifth visit, gait training was introduced to the patient in the parallel
bars for safety. The patient was instructed on proper gait with emphasis on equal weight bearing
through bilateral lower extremities and to emphasize heel strike and toe-off of the left lower
extremity with ambulation. The patient used bilateral upper extremity support with the use of
parallel bars for initial ambulation without an assistive device in the parallel bars. The patient
progressed to using one upper extremity, his right hand, for support when ambulating in parallel
bars. The patient progressed to ambulating in the clinic with a standard straight cane adjusted to
the patient’s height. The patient was educated on ambulation with cane status post left total knee
replacement and encouraged to continue ambulating with equal step and stride length, equal
weight bearing through bilateral lower extremities, and emphasis on heel strike and toe-off of the
left lower extremity. Side-stepping in parallel bars was also utilized for gait training to help
improve sideways stepping with activities of daily living. On the patient’s ninth visit, the patient
ambulated with no assistive device in the clinic with stand-by assist provided by the physical
therapist for safety. The patient continued to be encouraged to perform ambulation with equal
step and stride length, equal weight bearing through bilateral lower extremities, and heel strike
and toe-off of left lower extremity for proper gait mechanics.

Outcomes
The patient met all of his physical therapy goals upon discharge from outpatient rehabilitation.
He agreed to continue with his home exercise program to continue working on and improving his
strength, ROM, and gait.

6
Range of motion. At initial evaluation, his left knee AROM was recorded as 0-114 degrees. Left
knee PROM was recorded as 0-116 degrees. His ROM was measured and recorded every few
visits. At his first treatment session after his TKA surgery, his left knee AROM was recorded as
0-117 degrees. Left knee PROM was recorded as 0-120 degrees. His left knee ROM was
showing improvements directly after his surgery, at his first treatment session. On the patient’s
seventh visit, he got his staples removed that same day and his left knee ROM improved to 0-117
degrees AROM and 0-123 degrees PROM. The patient’s ROM continued to improve at each
visit, it was measured and recorded at his ninth visit as 0-122 degrees AROM and 0-128 degrees
PROM. At discharge, the patient’s left knee ROM was recorded for the last time at 0-120
degrees AROM and 0-126 degrees PROM. He improved his left knee ROM by 6 degrees of
AROM knee flexion and 10 degrees of PROM knee flexion. This demonstrates an improvement
in ROM when compared to his initial measurements at his initial evaluation.

Strength testing. Lower extremity strength was assessed using the Manual Muscle Testing
position and procedures provided by Reese.6 These tests were modified and taken with the patient
seated. Hip flexion, internal rotation, external rotation, abduction, knee flexion and extension,
and ankle dorsiflexion were taken on the left lower extremity. The patient demonstrated
improvements throughout bilateral lower extremities with manual muscle testing, specific
measurements are shown in Table 1.

Posture. The patient’s posture was assessed in standing. Upon visual inspection, the patient
continued to present with bilateral shoulders rounded forward, head forward, and increased
thoracic kyphosis, however, his left knee was no longer in an increased valgus position. He
presented with normal alignment of his knees bilaterally.

Pain. The patient’s pain score was recorded at each visit using the VAS. At the initial evaluation,
the patient reported a 0/10 of current, resting left knee pain, and reported a 6/10 of left knee pain
at its worse. At his first treatment session following his left TKA, he recorded a 0/10 on the VAS
for left knee pain. The patient was taking pain medication at the time for pain reduction. At the
patient’s third visit, his left knee pain increased to 1-2/10 at rest and 4-5/10 with activities. The
patient reported increased pain with activities including sit-to-stand transfers and ambulation. On
the patient’s fourth visit, he ranked his pain at 1-2/10 and consistently ranked his pain at that
level at each visit following until his 11th visit. He continued to report his minimal left knee pain
as an ache and reported his difficulty and pain with sit-to-stand transfers have been improving
with less pain with the transfer. On the patient’s eleventh and final visit, the patient reported
having no left knee pain and minimal to no pain with transfers and ambulation. The patient
demonstrated improvements in pain with pain reduction throughout treatments and reported no
left knee pain at discharge.

Outcome measure. We used the Lower Extremity Functional Scale (LEFS) to objectively
measure the patient’s functional status and progress of his left lower extremity status post left
TKA. The patient’s initial score was recorded at his first physical therapy treatment session
following his left TKA and recorded his score as 34.7. At discharge, after 6 weeks consisting of
twelve visits, the patient recorded a 49.5 on the LEFS. This is an improvement of 14.8 points
indicating detectable change following physical therapy interventions. Research suggests a
minimal detectable change of 6 points on the LEFS.8

7
Discussion
 This study is to evaluate a patient with a history of bilateral THAs and TKA and
determine if his new TKA rehabilitation will be helped, hindered, or not show much
difference when compared to patients with their initial joint replacement – If having prior
joint replacements would be beneficial or not for this patient's rate of recovery.
 Previous research is lacking on if other joint replacements are beneficial or not for
patient’s rehabilitation after another TKA so it is difficult to compare to previous
research.
 Possible barriers to achieving better outcomes could be the patient not being compliant
with HEP but reported being compliant.
 The patient had great motivation, family support, familiarity of exercises, and reported
compliance to HEP that were all positive factors that contributed to his outcomes.
 There could be future research including a randomized controlled trial including two
different groups, one group with a history of joint replacements and the other group have
no history of joint replacements. This will make it easier for a more direct comparison to
determine if joint replacements benefit rehab status post joint replacement or not.
 There could be future research reporting a specific rehab protocol to follow including
exercise and manual techniques that are easy for physical therapists to follow and
replicate that are known to be beneficial for patient’s status post joint replacement.

8
Table 1. Manual Muscle Test Measurements
Manual Muscle Testing Initial Eval Discharge (6 weeks)
Hip flexion Right 5/5 Left 5/5 Right 5/5 Left 5/5
Hip abduction Right 4/5 Left 4/5 Right 5/5 Left 5/5
Hip external rotation Right 4/5 Left 4/5 Right 5/5 Left 5/5
Hip internal rotation Right 4/5 Left 4/5 Right 5/5 Left 5/5
Knee flexion Right 5/5 Left 5/5 Right 5/5 Left 5/5
Knee extension Right 5/5 Left 5/5 Right 5/5 Left 5/5
Ankle dorsiflexion Right 3+/5 Left 3+/5 Right 5/5 Left 5/5

9
References

1. Inacio MCS, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total
knee arthroplasty in the United States - an alternative projection model. Osteoarthritis
Cartilage. 2017;25(11):1797-1803. doi:10.1016/j.joca.2017.07.022
2. Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis:
estimates from the global burden of disease 2010 study. Ann Rheum Dis.
2014;73(7):1323-1330. doi:10.1136/annrheumdis-2013-204763
3. Bade MJ, Kohrt WM, Stevens-Lapsley JE. Outcomes before and after total knee
arthroplasty compared to healthy adults. J Orthop Sports Phys Ther. 2010;40(9):559-567.
doi:10.2519/jospt.2010.3317
4. Walker MJ, Boyles RE, Young BA, et al. The effectiveness of manual physical therapy
and exercise for mechanical neck pain: a randomized clinical trial. Spine (Phila Pa 1976).
2008;33(22):2371-2378. doi:10.1097/BRS.0b013e318183391e
5. Reese NB, Bandy W. Joint Range of Motion and Muscle Length Testing. 3rd ed. St. Louis,
MO: Elsevier Inc; 2016
6. Reese NB. Muscle and Sensory Testing, 3rd Ed. St. Louis, MO: Elsevier; 2012: 5-11.
7. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement
of acute pain. Acad Emerg Med. 2001;8(12):1153-1157. doi:10.1111/j.1553-
2712.2001.tb01132.x
8. Mehta SP, Fulton A, Quach C, Thistle M, Toledo C, Evans NA. Measurement Properties
of the Lower Extremity Functional Scale: A Systematic Review. J Orthop Sports Phys
Ther. 2016;46(3):200-216. doi:10.2519/jospt.2016.6165
9. Rowlands B. The Efficacy of Patella Mobilization in Patients Suffering from
Patellofemoral Pain Syndrome. South Africa: Durban University of Technology; 1999
10. Karaborklu Argut S, Celik D, Kilicoglu OI. The Combination of Exercise and Manual
Therapy Versus Exercise Alone in Total Knee Arthroplasty Rehabilitation: A
Randomized Controlled Clinical Trial. PM R. 2021;13(10):1069-1078.
doi:10.1002/pmrj.12542

10