High-Velocity Quadriceps Exercises Compared to Slow-Velocity Quadriceps Exercises Following Total Knee Arthroplasty: A Randomized Clinical Study

Rehabilitation Techniques Before and After Total Knee Arthroplasty for a Better Quality of Life

The most important gold standard treatment following advanced knee osteoarthritis is total knee arthroplasty. Following surgery of total knee replacement, the majority of patients report decreased pain and successful long-term results, but recovery is unpredictable, and most patients continue to exhibit muscle weakness in their lower limbs and functional limitations in comparison to similarly aged control individuals. The goal of this review article was to systematically review different articles containing controlled and randomized studies to find out the effectiveness of outpatient care postoperatively on short- and long-term functional recovery. The purpose of this review article is to investigate the possible advantages of pre- and postoperative rehabilitation as well as the value of exercise regimen recommendations following total knee replacement. The following interventions after total knee arthroplasty are discussed in this review article: preoperative education and exercises, continuous passive movement, strengthening interventions, aquatic therapy, balanced training, tourniquet exposure, use of alignment and implants, role of apps in phones and different wearable devices, influence of postoperative protocols, knee bracing, neuromuscular electrical stimulation, and clinical environment. Strengthening and intense functional exercises for patients above 45 years of age, in land or water programs like aquatic activities, with the increasing intensity of the exercises in accordance with the patient's progress, should be included in the best outpatient physical therapy protocols. Because these exercises are so precisely personalized, the best long-term effects after surgery may come from outpatient physiotherapy performed in a clinical setting under the supervision of a registered physiotherapist or medical professional. This review article also includes the change in the quality and well-being of a patient's life who has undergone total knee arthroplasty and practiced the rehabilitation techniques.

Osteoarthritis Progression: Mitigation and Rehabilitation Strategies

Osteoarthritis is the most common form of arthritis and is a substantial burden for patients with the disease. Currently, there is no cure for osteoarthritis, but many emerging therapies have been developed to aid in the mitigation of disease progression. When osteoarthritis reaches the end-stage of disease many patients undergo total joint arthroplasty to improve quality of life, yet some experience persistent pain and mobility limitations for extended periods following surgery. This review highlights recent therapeutic advancements in osteoarthritis treatment consisting of pharmacologics, nutraceuticals, biologics, and exercise while emphasizing the current state of post-arthroplasty rehabilitation.

Reporting of post-operative rehabilitation interventions for Total knee arthroplasty: a scoping review

Objective

The aim of this study was to evaluate the completeness of reporting of exercise adherence and exercise interventions delivered as part of clinical trials of post-operative total knee replacement (TKA) rehabilitation.

Design: Scoping review

Literature search

A literature search was conducted in PubMed, EMBASE, AMED, CINAHL, SPORTDiscus and Cochrane Library.

Study selection criteria

All randomized controlled trials (RCT) that examined post-operative exercise-based interventions for total knee arthroplasty were eligible for inclusion. Studies that were multifactorial or contained exercise interventions for both hip and knee arthroplasty were also included.

Data synthesis

The definition, type of measurement used and outcome for exercise adherence were collected and analyzed descreptively. Quality of reporting of exercise interventions were assessed using the Consensus for Exercise Reporting Tool (CERT) and the Cochrane Risk of Bias Tool.

Results

There were a total of 112 RCTs included in this review. The majority of RCTs (63%, n = 71) did not report exercise adherence. Only 23% (n = 15) of studies provided a definition of adherence. RCTs were of poor quality, with 85% (n = 95) of studies having high or unclear risk of bias. Reporting of exercise interventions was poor, with only 4 items (of 19) (21%) of the CERT adequately reported (88–99%), with other items not fulfilled on at least 60% of the RCTs. There were no RCTs that had fulfilled all the criteria for the CERT.

Conclusion

The RCTs included in this study poorly reported exercise adherence, as well as description of the post-operative TKA rehabilitation intervention. Future RCTs should use valid and reliable measures of adherence and a proper tool for reporting of exercise interventions (e.g., CERT, TiDER).

Pre-registration

OSF:https://osf.io/9ku8a/

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04460-w.

Efficacy and Safety of Lower Limb Progressive Resistance Exercise for Patients With Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To evaluate the efficacy and safety of progressive resistance exercise (PRE) for patients with total knee arthroplasty (TKA) in a meta-analysis.

DATA SOURCES

PubMed, MEDLINE, Cochrane's Library, and EMBASE databases.

STUDY SELECTION

Randomized controlled trials evaluating the effect of PRE on mobility and function in patients with TKA.

DATA EXTRACTION

A random-effects model was applied if significant heterogeneity was detected; otherwise, a fixed-effects model was applied.

DATA SYNTHESIS

Seven randomized controlled trials. Compared with a rehabilitation program without PRE, physiotherapy including PRE was associated with improvements in the 6-minute walking test (weighed mean difference [WMD], 19.22m; P=.04) with a wide confidence interval (CI, 0.48∼37.95). However, sensitivity analysis by omitting 1 study with preoperative rehabilitation revealed nonsignificant results (WMD, 15.15m; P=.16). Moreover, PRE did not significantly improve the maximal walking speed (WMD, 0.05m/s, 95% CI, 0.00∼0.11; P=.05). However, PRE was associated with improved knee strength of extension (standardized mean difference [SMD], 0.72; 95% CI, 0.47∼0.96; P<.001) and flexion (SMD, 0.47; 95% CI, 0.19∼0.74; P<.001) but not self-reported physical function (SMD, -0.17; 95% CI, -0.37∼0.03; P=.10) or changes in pain score (SMD, 0.11; 95% CI, -0.15∼0.37; P=.40). PRE did not increase the risk of adverse events (risk ratio, 1.19; 95% CI, 0.52∼2.71; P=.68).

CONCLUSIONS

PRE may lead to improvements in physical function among patients receiving a TKA. PRE leads to higher ultimate strength in the surgical knee and is safe to perform.

Exploration of Habitual Walking Behavior and Home-Based Muscle Power Training in Individuals With Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to investigate the effects of a home-based muscle power training program on muscle strength and power, functional performance, and physical activity behavior in individuals at least 6 months posttotal knee arthroplasty.

METHODS

Twelve men and women, mean age 63.9 (6.8) and 6 months to 2 years posttotal knee arthroplasty unilateral or bilateral), completed this study. Participants were randomly assigned to the home-based power training intervention or step-monitoring comparison group. Quadriceps muscle strength and power, 6-minute walk test, functional leg power, and habitual walking behavior (average daily steps, minutes per week of moderate to vigorous physical activity) were assessed before and after intervention and then compared between and within groups.

RESULTS

The authors found no significant differences between the groups on amount of change in any of the outcomes, but mixed results on differences within each of the groups on the outcome measures.

CONCLUSION

There were no differences between the groups for amount of change on the outcome measures the authors selected. Although within group differences varied slightly for each group, it was not enough to justify the more expensive home-based power training over the simpler step-monitoring intervention.

Rehabilitation protocols following total knee arthroplasty: a review of study designs and outcome measures

Total knee arthroplasty (TKA) is among the most common elective procedures performed worldwide. Recent efforts have been made to significantly improve patient outcomes, specifically with postoperative rehabilitation. Despite the many rehabilitation modalities available, the optimal rehabilitation strategy has yet to be determined. Therefore, this systematic review focuses on evaluating existing postoperative rehabilitation protocols. Specifically, this review analyses the study designs, rehabilitation methods, and outcome measures of postoperative rehabilitation protocols for TKA recipients in the past five years. The PubMed, EMBASE, and Cochrane Library databases were queried for studies evaluating rehabilitation protocols following primary TKA. Of the 11,013 studies identified within the last five years, 70 met the inclusion and exclusion criteria. After assessing for relevance and removing duplicates, a final count of 20 studies remained for analysis. Level-of-evidence was determined by the American Academy of Orthopaedic Surgeons (AAOS) classification system. Our findings demonstrated that continuous passive motion and inpatient rehabilitation may not provide additional benefit to the patient or healthcare system. However, early rehabilitation, telerehabilitation, outpatient therapy, high intensity, and high velocity exercise may be successful forms of rehabilitation. Additionally, weight-bearing biofeedback, neuromuscular electrical stimulation, and balance control appear to be beneficial adjuncts to conventional rehabilitation. Postoperative rehabilitation following TKA facilitates patient recovery and improves quality of life. This systematic review analyzed the existing rehabilitation protocols from the past five years. Some studies did not accurately describe the conventional rehabilitation protocols, the duration of therapy sessions, and the timing of these sessions. As such, future studies should explicitly describe their methodology. This will allow high-quality assessments and the conception of standardized protocols.

Rate of torque development is the primary contributor to quadriceps avoidance gait following total knee arthroplasty

BACKGROUND

Following rehabilitation for total knee arthroplasty, "quadriceps avoidance gait", defined by limited knee flexion angle excursion during walking, persists and contributes to poor long-term outcomes. Given the presence of several post-surgical impairments, identifying the contribution of multiple factors to knee flexion angle excursion is important to developing targeted interventions to improve recovery after total knee arthroplasty.

RESEARCH QUESTIONS

Which outcomes continue to improve following rehabilitation for total knee arthroplasty? What are the primary contributors to impaired knee flexion angle excursion during walking following total knee arthroplasty?

METHODS

Peak muscle strength and rate of torque development of the quadriceps, hip abductors, and hip external rotators, five-time sit-to-stand test, Knee Injury & Osteoarthritis Outcome Score, and gait mechanics were assessed in 24 participants at three and six months post-surgery. Paired sample t-tests or Wilcoxon Signed-Rank tests were used to compare outcomes between assessments. Stepwise multiple linear regression were used to assess the contribution of each measure to knee flexion angle excursion.

RESULTS

Significant improvements were noted in all outcomes except hip external rotation rate of torque development, gait speed, and knee flexion angle excursion. Quadriceps rate of torque development and knee pain significantly contributed to knee flexion angle excursion at three months (Adjusted R² = 0.342), while quadriceps rate of torque development and peak hip external rotation strength significantly contributed at six months (Adjusted R² = 0.436).

SIGNIFICANCE

While higher pain levels at three months and greater peak hip external rotation muscle strength at six months contribute to impaired knee flexion angle excursion, quadriceps rate of torque development was the primary contributor to knee flexion angle excursion at both three and six months after surgery. Implementing strategies to maximize quadriceps rate of torque development during rehabilitation may help to reduce quadriceps avoidance gait after total knee arthroplasty.

Different improvement trends in gait function and quadriceps strength early after total knee arthroplasty

[Purpose] Improved quadriceps strength is a primary target of rehabilitation early after total knee arthroplasty. However, patients demonstrate varying improvement trends in gait function and quadriceps strength. This study evaluated the relationship between improvements in quadriceps strength and gait function. [Participants and Methods] The study included 49 patients who were scheduled to undergo unilateral total knee arthroplasty. Gait function, bilateral quadriceps strength, and pain were assessed in all patients. All assessments were performed preoperatively and at 2 and 3 weeks postoperatively. [Results] A significant correlation between gait function and the quadriceps strength on the operated side was observed preoperatively and 3 weeks postoperatively. The quadriceps strength on the non-operated side was significantly correlated with gait function at all time points. Multiple regression analysis showed that the quadriceps strength on the non-operated side was significantly associated with gait function, except the gait speed at 2 weeks. However, the quadriceps strength on the operated side was not observed to be an independent variable at all time points. [Conclusion] The quadriceps strength on the operated side is not an important determinant of gait function. It may be necessary to reconsider typical rehabilitation programs by focusing on the quadriceps strength on the operated side in patients undergoing total knee arthroplasty.