Total Knee Replacements: A little look at the research

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Total Knee Replacements: A little look at the research



There is research to suggest that total knee arthroplasty improves health related quality of life in 90% of patients (NIH, 2003) however functional ability 1 year following surgery remains lower than that of an age matched healthy adult (Woodhouse et al, 1998).

Researchers found they had 18% slower walking speed51% slower stair-climbing speed, and deficits of nearly 40% in quadriceps strength at 1 year post TKR compared to controls (Woodhouse, 1998).

With the continuing cuts in the NHS it is important for all of us to back up our thoughts with evidence and educate people on our worth in not only improving quality of life and improving long term results of surgery but to educate people on the core values of physiotherapy in promoting health, self management and empowering those to take responsibility for their health.

 Fast facts

An interesting study by Bade et al (2011) investigated the use of a high intensity rehabilitation and its effects on functional outcomes.  Participants in the high intensity rehab followed a protocol and attended physio 2-3 x per week for 12 weeks. In total they attended 25 visits over the 12 weeks compared to 16 visits over 8 weeks in the control group.

The high-intensity rehabilitation program described in this cohort study demonstrated significantly greater short-term and long-term strength and functional performance increases compared to a lower intensity rehabilitation program (Bade et al, 2011). Major weaknesses of the study were its small sample size, lack of randomisation and blinding but it does offer a stepping stone for one to consider when treating these patients.

Got some evidence to add? Please post in our forum

Now I don’t know about you but in my local PCT some patients are not even offered post op physio?! With increased strain on the NHS it is important that we are educating patients on evidence which may help improve compliance with their home exercises ie.

“Research suggests that if you follow this program 3 times weekly under our guidance (be sure to give them a copy) you are likely to have improved long term function.”

It is also important that patients know that they can seek  additionally physio privately if  there is not suitable funding within the NHS. The age-old rivalry between private practice and NHS needs to be left behind so that we can work together to offer optimum patient care.

Here is a copy of the program used which is publically and freely available here

Figure 1.  (Bade et al, 2011)


High-Intensity Rehabilitation Program

Phase 1 (Weeks 0–2)

  • Supine knee flexion (heel slides)
  • Short-arc knee extensions
  • Standing bilateral squats
  • Sidelying hip external rotation, with hips flexed to 45° and knees flexed to 90° (clams)
  • Sidelying hip adduction
  • Supine ankle plantar flexion and dorsiflexion (ankle pumps)



  • When able to complete 2 × 8 repetitions without fatigue; NPRS at rest, <5/10; ROM, >15°–80°

Phase 2 (Weeks 0–4)

  • Seated single-leg knee extension*
  • Straight leg raise*
  • Standing hamstring curls*
  • Sidelying hip adduction*
  • Sidelying hip abduction*
  • Standing bilateral calf raises
  • Repeated sit-to-stand transfers
  • Marching or single-limb stance
  • Multidirectional stepping



  • When able to complete 2 × 8 reps without fatigue; NPRS at rest, <5/10; ROM, >15°–90°

Phase 3 (Weeks 2–12)

  • Seated single-leg knee extension*
  • Seated single-leg knee flexion*
  • Single-leg press*
  • Single-leg calf press*
  • Standing hip extension, flexion, abduction, and adduction*
  • Step-ups, side step-ups, step-downs
  • Forward lunging
  • Single-limb stance progression (shoe to sock to foam, with eyes open, then with eyes closed)
  • Tilt board squats
  • Wall slides to 90° of knee flexion
  • Stability ball supine hip extension



  • When able to complete 2 × 8 repetitions without fatigue; NPRS at rest, <3/10; ROM, >10°–100°

Phase 4 (Weeks 6–12)

  • Seated single-leg knee extension (eccentric)*
  • Seated single-leg knee flexion (eccentric)*
  • Single-leg press (eccentric)*
  • Single-leg calf press (eccentric)*
  • Standing hip extension, flexion, abduction, and adduction*
  • Step-ups, side step-ups, step-downs
  • Multidirectional lunging
  • Star excursion balance reaching
  • Wall slides with 5- to 10-second endurance holds at 90°
  • Stability ball supine combined hip extension with knee flexion
  • Agility exercises: side-shuffle, backward walking, and braiding
  • Single-limb stance progression

Read More:


Bade MJ , Stevens-Lapsley JE . Early high-intensity rehabilitation following total knee arthroplasty improves outcomes . J Orthop Sports Phys Ther . 2011;41:932–941

Mizner RL, Petterson SC, Stevens JE, Vandenborne K, Snyder-Mackler L. Early quadriceps strength loss after total knee arthroplasty. The contributions of muscle atrophy and failure of voluntary muscle activation. J Bone Joint Surg Am. 2005;87:1047–1053.

National Institutes of Health. NIH Consensus Statement on total knee replacement. NIH Consens State Sci Statements. 2003;20:1–34.

Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects. Phys Ther. 1998:78:248–258.

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