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FOTO Rehab Outcomes Blog

Exercise Interventions and Outcomes after a Total Knee Arthroplasty

This recent research that happens to be popping up online has me pause and wonder if it truly analyzed the situation of both the exercise interventions after a total knee arthroplasty and the outcomes.


In order to share my thoughts, I read found the studies that led up to this particular study. Initially the researchers proposed a clinical trial to compare behavioral support to usual care after a total knee arthroplasty. The study was completed in August 2012, yet no results are posted for review. The proposal included the use of the WOMAC and also functional tests. I couldn't find a final published study that put the two interventions head to head.

I can find the feasibility of using phone calls and coaching interventions to use as an option for individuals who have recently underwent surgical intervention for a total knee arthroplasty.

The group of patients in the above study that were randomized in the above study to usual care - either outpatient physical therapy services or home health services - were analyzed for the utilization of services. The study also focused on determining what kind of care was provided. The study provided pre-WOMAC scores, but did not provide any post-WOMAC scores.

This current study that includes the exact same group of patients in the usual care arm the first clinical trial focuses on the lack of detail provided in documentation to truly note the details of the exercise interventions. The study fails to provide details on the actual outcomes of care (the WOMAC, the mental and physical components of the SF-36), the actual results for the timed stair climb and the amount of knee flexion attained, in order for a clinician to analyze the final results. The researchers did not provide the minimal clinically important difference for any of the outcome measures. As I reviewed the types of exercises, I saw that biking was not included in the study. I don't understand how it lacked sufficient detail for it to be excluded as an exercise.  The study also ignored the importance of a home exercise program. The activities performed in the clinic during a treatment session are not the only aspect that helps a patient attain outcomes after a total knee arthroplasty. 

I believe the biggest take home message is not related to outcomes of care as much as documentation of care. The exercise, dose and progression need to be easily noted by anyone reviewing records.  Without the actual raw data on the outcomes of care (both patient reported and functional), I have no way to truly know if optimal outcomes were actually achieved.

You'll find the abstract to the recent study below.

Characteristics of Usual Physical Therapy Post‐Total Knee Replacement and their Associations with Functional Outcomes




Although total knee replacement surgery (TKR) is highly prevalent and generally successful, functional outcomes post‐TKR vary widely. Most patients receive some physical therapy (PT) following TKR, but PT practice is variable and associations between specific content and dosage of PT interventions and functional outcomes are unknown. Research has identified exercise interventions associated with better outcomes but studies have not assessed whether such evidence has been translated into clinical practice. We characterized the content, dosage and progression of usual post‐acute PT services following TKR, and examined associations of specific details of post‐acute PT with patients’ 6‐month functional outcomes.


Post‐acute PT data were collected from patients undergoing primary unilateral TKR and participating in a clinical trial of a phone‐based coaching intervention. PT records from the terminal episode of care were reviewed and utilization and exercise content data were extracted. Descriptive statistics and linear regression models characterized PT treatment factors and identified associations with 6‐month outcomes.


We analyzed 112 records from 30 PT sites. Content and dosage of specific exercises and incidence of progression varied widely. Open chain exercises were utilized more frequently than closed chain (median and interquartile range (21(4,49) vs 13(4,28.5)). Median (interquartile range) occurrence of progression of closed and open chain exercise was 0 (0,2) and 1 (0,3) respectively. Shorter timed stair climb was associated with greater total number of PT interventions and use and progression of closed chain exercises.


Data suggest that evidence‐based interventions are under‐utilized and dosage may be insufficient to obtain optimal outcomes.


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