Physical Therapist Management of Total Knee Arthroplasty PDF

Clinical Practice Guidelines Physical Therapist Management of D.U. Jette, PT, DPT, DSc, FAPTA, MGH,...

Clinical Practice Guidelines Physical Therapist Management of D.U. Jette, PT, DPT, DSc, FAPTA, MGH, Institute of Health Professions, Boston, Massachusetts. S.J. Hunter, PT, DPT, OCS, Total Knee Arthroplasty Rehabilitation Services, Intermountain Healthcare, 36 South State Street, Salt Lake City, UT 84111 (USA). Address all Diane U. Jette, Stephen J. Hunter, Lynn Burkett, Bud Langham, David S. correspondence to Dr Hunter at: [email protected]. Logerstedt, Nicolas S. Piuzzi, Noreen M. Poirier, Linda J.L. Radach, Jennifer E. L. Burkett, MBA, BSN, RN, ONC, Ritter, David A. Scalzitti, Jennifer E. Stevens-Lapsley, James Tompkins, Joseph National Association of Orthopaedic Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 Zeni Jr, for the American Physical Therapy Association Nurses (NAON), Wyomissing, Pennsylvania. B. Langham, PT, MBA, Home Health and Hospice Services, Encompass A clinical practice guideline on total knee arthroplasty was developed by an American Health, Birmingham, Alabama. Physical Therapy (APTA) volunteer guideline development group that consisted of physical D.S. Logerstedt, PT, PhD, Department therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on of Physical Therapy, University of the systematic reviews of current scientific and clinical information and accepted approaches Sciences, Philadelphia, Pennsylvania. to management of total knee arthroplasty. N.S. Piuzzi, MD, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio. N.M. Poirier, PT, DPT, Department of Orthopedics and Rehabilitation, University of Wisconsin (UW) Health, Madison, Wisconsin. L.J.L. Radach, Consumers United for Evidence Based Healthcare, Lake Forest Park, Washington. J.E. Ritter, PT, Department of Rehabilitation Services/Physical Therapy, University of Pittsburgh Medical Center (UPMC) St Margaret Hospital/Catholic Relief Services, Pittsburgh, Pennsylvania. D.A. Scalzitti, PT, PhD, OCS, School of Medicine and Health Sciences, George Washington University, Washington, DC. J.E. Stevens-Lapsley, PT, MPT, PhD, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver & Health Sciences Center, Denver, Colorado. J. Tompkins, PT, DPT, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Scottsdale, Arizona. J. Zeni Jr, PT, PhD, Department of Physical Therapy, University of Delaware, Newark, Delaware. [Jette DU, Hunter SJ, Burkett L, et al. Physical therapist management of total knee arthroplasty. Phys Ther. 2020;100:1603–1631.] © The Author(s) 2020. Published by Oxford University Press on behalf of the American Physical Therapy Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non- Commercial License (http://creative commons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] Published Ahead of Print: June 16, 2020 Accepted: May 14, 2020 Submitted: February 7, 2020 Post a comment for this article at: https://academic.oup.com/ptj 2020 Volume 100 Number 9 Physical Therapy 1603 Total Knee Arthroplasty T his clinical practice guideline (CPG) is based on a health, well-being, and quality of life. Typically, the systematic review of published studies with regard physical therapist is a graduate of a physical therapist to the physical therapist management of patients education program accredited by the Commission on undergoing total knee arthroplasty. In addition to Accreditation in Physical Therapy Education and is providing practice recommendations, this guideline also licensed to practice physical therapy. Orthopedic highlights limitations in the literature, areas that require surgeons, adult primary care clinicians, geriatricians, future research, intentional vagueness, and quality hospital-based adult medicine specialists, physiatrists, improvement activities. occupational therapists, nurse practitioners, physician Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 assistants, emergency clinicians, and other health care This guideline is intended to be used by all qualified and professionals who routinely see this type of patient in appropriately trained physical therapists involved in the various practice settings may also benefit from this management of patients undergoing total knee guideline. This guideline is not intended for use as a arthroplasty (TKA). It is also intended to serve as an benefits determination document. information resource for decision makers and developers of practice guidelines and recommendations. Care for individuals undergoing TKA is based on decisions made by them in consultation with their health care team, which may comprise physicians, surgeons, Overview nurses, physical therapists, and occupational therapists. Goals and Rationale Care includes conservative management approaches and The purpose of this CPG is to help improve treatment consideration of CPGs such as the American Academy of based on the current best evidence. Current Orthopaedic Surgeons’ (AAOS) “Evidence-Based Clinical evidence-based medicine standards demand that clinicians Practice Guideline on the Surgical Management of use the best available evidence in their clinical decision Osteoarthritis of the Knee.”1 making, incorporate clinical expertise, and consider the patient’s values. To assist clinicians, this guideline contains Once the individual (or advocate) has been informed of a systematic review of the available literature regarding the nature of the available therapies and their rationale, the management of patients undergoing TKA. The duration, benefits, and risks and has discussed the options systematic review detailed herein was conducted on with their health care provider, an informed and shared studies published between 1995 and 2018 and decision can be made. demonstrates where there is good evidence, where evidence is lacking, and the topics that future research must target in order to improve the management of Patient Population patients undergoing TKA. This guideline addresses the management of adult patients with knee osteoarthritis undergoing primary TKA. Musculoskeletal care is provided in many different It is not intended to address management of revision or settings by many different providers. This guideline is an partial knee arthroplasty, pediatric patients, or patients educational tool to guide qualified clinicians through a with rheumatoid arthritis. In addition, this guideline is not series of treatment decisions in an effort to improve intended to address nonoperative management of patients quality and efficiency and reduce unwarranted variation with osteoarthritis. of care. Recommendations are part of evidence-based practice, and the patient’s wants and needs must be Burden of Disease considered in the clinical decision-making process. This Chronic knee pain is a leading cause of musculoskeletal guideline should not be construed as including all proper disability in the United States. This condition often leads methods of care or excluding methods of care reasonably to TKA (also known as total knee replacement), which is directed to obtaining the same results. The ultimate the most commonly performed orthopedic surgery in the judgment regarding any specific procedure or treatment lower extremity. In 2013, 662,545 TKAs were performed, a must be made in light of all circumstances presented by steady increase in the number of procedures since 1992.2 the patient, including preferences, safety, and Although the length of stay has declined during the same postoperative time period, as well as the needs and time period—from 8.9 days to 3.4 days (67%)—hospital resources particular to the locality or institution. charges have steadily increased.2 In 2013, the total hospital charges for TKA were $36.64 billion.2 Intended Users Additionally, the number of TKAs performed annually in This guideline is intended to be used by physical the United States is expected to increase by 855% between therapists for the management of patients who will 2012 and 2050, equating to 2854 procedures per 100,000 undergo or have undergone TKA. Physical therapists are US citizens over 40 years of age.3 In 2010, the prevalence health care professionals who help individuals maintain, of knee osteoarthritis in North America was 3.1%, and restore, and improve movement, activity, and functioning, globally the prevalence was 3.8%. Prevalence was higher thereby enabling optimal performance and enhancing in women and peaked at around 50 years of age. Globally, 1604 Physical Therapy Volume 100 Number 9 2020  Total Knee Arthroplasty Future Research Consideration for future research is provided for each recommendation within this document. Methods The methods used to create this CPG were intended to minimize bias and enhance transparency in the selection, appraisal, and analysis of the available evidence. These Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 processes are vital to the development of reliable, transparent, and accurate clinical recommendations for management of patients undergoing TKA.6 Methods from the APTA Clinical Practice Guideline Process Manual 6 and AAOS Clinical Practice Guideline Methodology7 were used in the development of this CPG. This CPG evaluates the effectiveness of approaches in the management of patients undergoing TKA. APTA sought out the expertise of the AAOS Evidence-Based Medicine Unit as paid consultants to assist in the creation of this CPG. The GDG consisted of members from APTA and its representative sections, AAOS, the National Association of Orthopaedic Nurses, and a patient safety activist from Figure. Consumers United for Evidence-Based Healthcare. All Study attrition flowchart. GDG members, APTA staff, and methodologists were free of potential conflicts of interest relevant to the topic under hip and knee osteoarthritis was ranked as the 11th highest study, as recommended by CPG development experts.8 contributor to disability among almost 300 health conditions.4 This CPG was prepared by the APTA GDG with the assistance of APTA staff and the AAOS Clinical Quality and Value Department (staff evidence-based medicine Etiology methodologists). To develop this guideline, the GDG held TKA consists of resection of the diseased or degenerative an introductory meeting on September 22, 2017, to articular surfaces of the knee, replacing the surface with establish the scope of the CPG. The GDG defined the metal and polyethylene prosthetic components. The scope by creating PICO(T) questions (population, disease or degeneration is a result of destruction of the intervention, comparison, outcome, and time) that joint cartilage from osteoarthritis, rheumatoid arthritis, directed the literature search. The medical librarian from posttraumatic degenerative joint disease, or other AAOS created and executed the searches. pathologic conditions accounting for more than 95% of Supplementary Appendix 1 contains the search strategies TKA surgeries.5 used. AAOS chose the included studies (Figure; Supplementary Appendix 2), performed quality Risk Factors assessments, and wrote initial recommendations based on Both treatable or modifiable risk factors and the published guideline methodology. The GDG nonmodifiable risk factors will impact outcomes after performed final reviews of recommendations, provided TKA. rationale in the context of physical therapist practice, and adjusted the strength of the recommendations depending An understanding and appreciation of the risk factors on the magnitude of benefit, risk, harm, and cost. helps inform care and determine prognosis. The guideline development group (GDG; also “work group”) (Appendix) Additional background on the people and processes identified aspects of the relationship between risk factors involved in the creation of this guideline are provided in and outcomes in this patient population and made specific Supplementary Appendix 1. searches and recommendations. Refer to the specific recommendations below for details. A summary of Best-Evidence Synthesis recommendations is provided in Table 1. The guideline includes only the best available evidence for any given outcome addressing a recommendation. Potential Benefits, Risks, Harms, and Costs Accordingly, the highest-quality evidence for any given The potential benefits, risks, harms, and costs are outcome is included first, if it was available. In the provided for each recommendation within this document. absence of 2 or more occurrences of an outcome based on 2020 Volume 100 Number 9 Physical Therapy 1605 Total Knee Arthroplasty Table 1. Summary of Recommendations for Total Knee Arthroplasty (TKA) Interventions Rating Practice Recommendations Preoperative exercise program ♦ Physical therapists should design preoperative exercise programs and teach patients undergoing total knee arthroplasty (TKA) to implement strengthening and flexibility exercises. Preoperative education ♦♦♦ It is the consensus of the work group that physical therapists or other team members should provide Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 preoperative education for patients undergoing TKA, including, at a minimum: patient expectations during hospitalization and factors influencing discharge planning and disposition, the postoperative rehabilitation program, safe transferring techniques, use of assistive devices, and fall prevention. Continuous passive motion ♦ Physical therapists should NOT use CPMs for patients who have undergone primary, uncomplicated (CPM) device use for TKA. mobilization Cryotherapy ♦ Physical therapists should teach patients and other care givers use of cryotherapy and encourage its use for early postoperative pain management for patients who have undergone TKA. Physical activity ♦♦♦ It is the consensus of the work group that physical therapists should develop an early mobility plan and teach patients who have undergone TKA regarding the importance of early mobility and appropriate progression of physical activity, based on safety, functional tolerance, and physiological response. Motor function training  Physical therapists should include motor function training (eg, balance, walking, movement (balance, walking, movement, symmetry) for patients who have undergone TKA. symmetry) Postoperative knee ♦♦♦ It is the consensus of the work group that physical therapists should teach and encourage patients to range-of-motion (ROM) exercise implement passive, active assistive, and active ROM exercises for the involved knee following TKA. Immediate postoperative knee ♦♦ To reduce immediate postoperative blood loss and swelling in the first 7 days after surgery, physical flexion during rest for blood loss therapists or other team members may teach patients to position the operated knee in some degree and swelling of flexion (30◦ -90◦ ) while resting. Neuromuscular electrical ♦ Physical therapists should use NMES for patients who have undergone TKA to improve quadriceps stimulation (NMES) muscle strength, gait performance, performance-based outcomes, and patient-reported outcomes. Resistance and intensity of ♦ Physical therapists should design, implement, teach, and progress patients who have undergone TKA strengthening exercise in high-intensity strength training and exercise programs during the early postacute period (ie, within 7 days after surgery) to improve function, strength, and ROM. Prognostic factors: body mass ♦ Physical therapist management should take into consideration the following factors when index (BMI), depression, determining prognosis, providing treatment, and engaging in informed decision making and preoperative ROM, physical expectation setting with patients undergoing TKA: function and strength, age, Higher BMI is associated with more postoperative complications and worse postoperative outcomes. diabetes, number of comorbidities, and sex Depression is associated with worse postoperative outcomes. Preoperative ROM is positively associated with postoperative ROM but has minimal, if any, effect on physical function and quality of life. Preoperative physical function is positively associated with postoperative physical function. Preoperative strength is positively associated with postoperative physical function. Age is associated with mixed patient-reported, performance-based, and impairment-based outcomes. Diabetes is not associated with worse functional outcomes. A greater degree of comorbidity is associated with worse patient-reported outcomes. Sex is associated with both positive and negative effects on postoperative outcomes. Prognostic factors: tobacco and ♦♦♦ It is the consensus of the work group that active tobacco use and lack of patient support (eg, patient support environmental factors including, but not limited to, support and relationships) should be considered as prognostic/risk factors associated with less than optimal functional outcomes. Postoperative physical therapy ♦ Supervised physical therapist management should be provided for patients who have undergone supervision TKA. The optimal setting should be determined by patient safety, mobility, and environmental and personal factors. Group-based vs individual-based ♦♦ Physical therapists may use group-based or individual-based physical therapy sessions for patients therapy who have undergone TKA. (Continued) 1606 Physical Therapy Volume 100 Number 9 2020  Total Knee Arthroplasty Table 1. Continued Interventions Rating Practice Recommendations Physical therapy postoperative ♦ Physical therapist management should start within 24 hours of surgery and prior to discharge for timing patients who have undergone TKA. Physical therapy discharge ♦ It is the consensus of the work group that physical therapists should provide guidance to the care planning team and to the patient on safe and objective discharge planning, patient functional status, Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 assistance equipment, and services needed to support a safe discharge from the acute care setting. Outcomes assessment ♦♦♦ It is the consensus of the work group that physical therapists should collect data using the Knee Injury Osteoarthritis Outcomes Survey Joint Replacement (KOOS JR) as a patient-reported outcome measure and both the 30-Second Sit-to-Stand and Timed “Up and Go” (TUG) tests as performance-based outcomes to demonstrate the effectiveness of care provided. At a minimum, these measures should be collected at the first visit and upon conclusion of care from each setting. the highest-quality evidence, outcomes based on the next Voting on the Recommendations level of quality were considered until at least 2 or more GDG members agreed upon the strength of every occurrences of an outcome had been acquired. For recommendation. When changes were made to the example, if there were 2 “moderate”-quality occurrences strength of a recommendation based on the magnitude of of an outcome that addressed a recommendation, the benefit or potential risk, harm, or cost, the GDG voted in recommendation does not include “low”-quality person, via phone, or email and provided an explanation occurrences of evidence for this outcome. A summary of in the rationale. excluded articles can be viewed in Supplementary Appendix 1, and the data findings for each Role of the Funding Source recommendation can be viewed in Supplementary The American Physical Therapy Association, which Appendix 3. funded the volunteer GDG, provided coordination and played no role in the design, conduct, and reporting of the recommendations. Literature Searches The medical librarian conducted a comprehensive search Peer Review and Public Commentary of MEDLINE, Embase, and the Cochrane Central Register Following the formation of a final draft, the CPG review of Controlled Trials based on key terms and concepts draft was subjected to a 4-week peer review for additional from the PICO(T) questions. Retrospective input from external content experts and stakeholders. noncomparative case series, medical records review, More than 350 comments (Supplementary Appendix 4) meeting abstracts, meta-analyses, systematic reviews, were collected via an electronic structured review form. historical articles, editorials, letters, and commentaries All peer reviewers were required to disclose any potential were excluded. Bibliographies of relevant systematic conflicts of interest, which were recorded and, as reviews were hand searched for additional references. All necessary, addressed. databases were last searched on July 13, 2018, and searches were limited to publication dates from 1995 to 2018 and publications in the English language. After modifying the draft in response to peer review, the CPG was subjected to a 2-week public comment period. Commenters consisted of members of the APTA Board of Defining the Strength of the Recommendations Directors (Board), the APTA Scientific and Practice Affairs Judging the strength of evidence is only a steppingstone Committee (SPAC), all relevant APTA sections, stakeholder toward arriving at the strength of a CPG recommendation. organizations, and the physical therapy community at The operational definitions for the quality of evidence are large. More than 194 public comments were received. listed in Table 2, and rating of magnitude of benefits Revisions to the draft were made in response to relevant versus risk, harms, and cost is provided in Table 3. The comments. strength of recommendation, listed in Table 4, takes into account the quality, quantity, and trade-off among the benefits and harms of a treatment, the magnitude of a Recommendations treatment’s effect, and whether there are data on critical outcomes. Table 5 addresses how to link the assigned Preoperative Exercise Program ♦ grade with the level of obligation of each Physical therapists should design preoperative exercise recommendation. programs and teach patients undergoing total knee 2020 Volume 100 Number 9 Physical Therapy 1607 Total Knee Arthroplasty Table 2. Rating Quality of Evidence Rating of Overall Quality of Definition Evidence High Preponderance of Level 1 or 2 evidence with at least 1 Level I study. Indicates a high level of certainty that further research is not likely to change outcomes of the combined evidence. Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 Moderate Preponderance of Level 2 evidence. Indicates a moderate level of certainty that further research is not likely to change the outcomes direction of the combined evidence; however, further evidence may impact the magnitude of the outcome. Low A moderate level of certainty of slight benefit, harm, or cost, or a low level of certainty for moderate-to-substantial benefit, harm, or cost. Based on Level II thru V evidence. Indicates that there is some but not enough evidence to be confident of the true outcomes of the study and that future research may change the direction of the outcome and/or impact magnitude of the outcome. Insufficient Based on Level II thru V evidence. Indicates minimal or conflicting evidence to support the true direction and/or magnitude of the outcome. Future research may inform the recommendation. Table 3. Magnitude of Benefit, Risk, Harm, and Cost Rating of Definition Magnitude Substantial The balance of the benefits versus risk, harms, or cost overwhelmingly supports a specified direction. Moderate The balance of the benefits versus risk, harms, or cost supports a specified direction. Slight The balance of the benefits versus risk, harms, or cost demonstrates a small support in a specified direction. Table 4. Strength of Recommendations Strength Strength Visual Definition Strong  A high level of certainty of moderate-to-substantial benefit, harm, or cost, or a moderate level of certainty for substantial benefit, harm, or cost (based on a preponderance of Level 1 or 2 evidence with at least 1 Level 1 study). Moderate ♦ A high level of certainty of slight-to-moderate benefit, harm, or cost, or a moderate level of certainty for a moderate level of benefit, harm, or cost (based on a preponderance of Level 2 evidence, or a single high-quality RCT). Weak ♦♦ A moderate level of certainty of slight benefit, harm, or cost, or a low level of certainty for moderate-to-substantial benefit, harm, or cost (based on Level 2 through 5 evidence). Theoretical/ foundational ♦♦♦ A preponderance of evidence from animal or cadaver studies, from conceptual/theoretical models/principles, or from basic science/bench research; or published expert opinion in peer-reviewed journals that supports the recommendation. Best Practice ♦♦♦ Recommended practice based on current clinical practice norms; exceptional situations in which validating studies have not or cannot be performed yet there is a clear benefit, harm, or cost; or expert opinion. Research An absence of research on the topic or disagreement among conclusions from higher-quality studies on the topic. 1608 Physical Therapy Volume 100 Number 9 2020  Total Knee Arthroplasty Table 5. Linking Strength of Recommendation, Quality of Evidence, Rating of Magnitude, and Preponderance of Risk Versus Harm to the Language of Obligation Level of Obligation to Recommendation Quality of Evidence and Rating Preponderance of Benefit or Follow Strength of Magnitude Risk, Harm, or Cost the Recommendation Strong High quality and Benefit Must or Should moderate-to-substantial magnitude Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 or Moderate quality and substantial Risk, harms, or cost Must not or Should not magnitude Moderate High quality and Benefit Should slight-to-moderate magnitude or Moderate quality and moderate Risk, harms, or cost Should not magnitude Weak Moderate quality and slight Benefit May magnitude or Low quality and Risk, harms, or cost May not moderate-to-substantial magnitude Theoretical/ N/A Benefit May foundational Risk, harms, or cost May not Best Practice Insufficient quality and clear Benefit Should or May magnitude Risk, harms, or cost Should not or May not Research Insufficient quality and unclear Varies N/A magnitude or Conflicting high-to-moderate quality and conflicting magnitude arthroplasty (TKA) to implement strengthening and 3 months postsurgery with preoperative training.9 flexibility exercises. Evidence Quality: High; Modified WOMAC, subscales including function and Recommendation Strength: Moderate. stiffness, and pain using the visual analog scale (VAS) improved at 1 and 3 months postsurgery with preoperative quadriceps muscle exercise.16 Action Statement Profile SF-36 physical function component score improved Aggregate evidence quality: 6 high-quality studies9– 14 and at 12 weeks postsurgery with preoperative lower 3 moderate-quality studies.15– 17 extremity exercise.14 Knee Injury Osteoarthritis Outcomes Survey Rationale. Four high-quality studies9,11,13, 14 and 2 (KOOS) activities of daily living (ADL) improved at moderate-quality studies15,16 support the use of 6 weeks and 3 months postsurgery with preoperative physical therapy training/exercise programs preoperative physical therapy.15 for patients undergoing TKA and are associated with KOOS ADL, KOOS pain score, and EuroQol Five better postoperative functional outcomes. Summary of the Dimensions Questionnaire and visual analog scale outcomes measured and length of follow-up: (EQ5D –VAS) (generic health status instrument) improved at 6 weeks postsurgery with preoperative Total Western Ontario and McMaster Universities neuromuscular exercise program and standard Osteoarthritis Index (WOMAC), subscales including education.17 function, pain and stiffness, and the Medical Iowa Level of Assistance Scale total score improved Outcomes Study 36-Item Short Form Survey (SF-36) at 3 days postsurgery with preoperative physical physical function scores improved at 1 and therapy.11 2020 Volume 100 Number 9 Physical Therapy 1609 Total Knee Arthroplasty Hospital for Special Surgery Knee Rating improved Future research. Additional research on the effects of at 12 weeks postsurgery with preoperative preoperative exercise programs is required. This research cardiovascular conditioning.10 should examine specific regimens or recommendations Length of inpatient stay was reduced with for type, frequency, duration, and progression and preoperative training.9 should consider patient preferences. Outcomes related Stair Test improved at 1 and 3 months postsurgery to length of stay, discharge to home, patient satisfaction, with preoperative training.9 and return to activities and participation should be Timed “Up and Go” (TUG) Test improved at 1 and included. Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 3 months postsurgery with preoperative training.9 Value judgments. None were identified. Biodex overall stability index score improved at 6 weeks postsurgery with preoperative training.12 Intentional vagueness. Specific exercises are identified Knee flexion range of motion (ROM) improved at based on the individual patient. The preoperative 3 months postoperative with preoperative training.9 examination and evaluation guide the discussions for Knee extension ROM improved at 1 and 3 months appropriate interventions included in the plan of care. postsurgery with preoperative training.9 Quadriceps strength improved at 1 and 3 months Exclusions. None were identified. postsurgery with preoperative quadriceps training.16 Quality improvement. Organizations may use the Isometric hip abduction strength improved at 1 and completion of a preoperative visit to physical therapy that 3 months postsurgery with preoperative training.9 includes preoperative strengthening and flexibility Isometric knee flexion strength improved at 1 and instruction as a performance indicator. 3 months postsurgery with preoperative training.9 Isometric knee extension strength improved at Implementation and audit. Organizations may audit the 3 months postsurgery with preoperative training.9 rate of occurrence of preoperative physical therapy visits Fewer postoperative days were required to reach 90 that includes preoperative strengthening and flexibility degrees of knee flexion with preoperative instructions for patients who receive a TKA. exercise.13 Preoperative Education ♦♦♦ Potential benefits, risks, and harms of implementing It is the consensus of the work group that physical this recommendation. Benefits are as follows: therapists or other team members should provide preoperative education of patients undergoing TKA, Improved activities including, at a minimum, patient expectations during Decreased pain hospitalization and factors influencing discharge planning Improved balance and disposition, postoperative rehabilitation program, safe Improved knee flexion ROM transferring techniques, use of assistive devices, and fall Improved knee extension ROM prevention. Evidence Quality: Insufficient; Improved isometric knee and hip strength Recommendation Strength: Best Practice. Improved report of quality of life (eg, as measured by SF-36) Reduced length of stay of inpatient stay Action Statement Profile Aggregate evidence quality: There was 1 study of moderate quality18 that supported the use of preoperative Risk, harm, and/or cost are as follows: education to shorten inpatient length of stay and decrease medical expenses. No reported harms were associated with implementing this recommendation. Rationale. In light of limited evidence, the GDG Team members should be aware of potential believed that preoperative education supports best complications after TKA that may affect exercise practice and was in consensus with this recommendation. including incision healing, thromboembolism, and Patient education is an essential part of patient care in all joint stiffness/arthrofibrosis. While costs were not settings, particularly in an increasingly patient-centered reported in studies, there may be an expected health care environment. Ingadottir et al19 reported that associated expense. patients undergoing TKA experienced a significant difference in the knowledge they expected to have Benefit-harm assessment: With no reported risk or harm in preoperatively as compared with the information they the studies, there is a preponderance of evidence-supported were given by the time of hospital discharge. The authors benefit for this recommendation. found that the closer the match between expectations and 1610 Physical Therapy Volume 100 Number 9 2020  Total Knee Arthroplasty information given, the more satisfied patients were with Exclusions. None were identified. their care; however, they suggested that preoperative education did not completely fulfill patients’ expectations Quality improvement. Organizations may use the and that postoperative education was also important. completion of a preoperative visit to physical therapy that includes education as a performance indicator. Soeters et al20 implemented preoperative physical therapy education for patients with total joint arthroplasty (hip and knee) that included a one-time, one-on-one Implementation and audit. Organizations may audit the Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 educational session with a physical therapist and gave rate of occurrence of preoperative physical therapy visits patients access to a microsite providing additional that include education for patients who have undergone information about postoperative complications, TKA and its association with postoperative complication, precautions, and mobility. They found that patients length of stay, and patient satisfaction. reached the criteria for readiness for discharge from physical therapy services in the inpatient setting faster if Continuous Passive Movement Device they had the educational intervention. They also found that all patients accessed the microsite at least once, (CPM) Use for Mobilization ♦ suggesting a desire for knowledge. In a systematic review Physical therapists should NOT use CPMs for patients who of preoperative education for patients with total hip or have undergone primary, uncomplicated TKA. Evidence knee replacement in 2014, the evidence suggested that Quality: High; Recommendation Strength: Moderate. preoperative education might be a useful treatment adjunct, particularly in people with depression, anxiety, or Action Statement Profile unrealistic expectations.21 The review also noted the low Aggregate evidence quality: 4 high-quality studies,22–25 6 risks associated with the intervention. moderate-quality studies,26–31 and 2 low-quality studies.32 ,33 Potential benefits, risks, and harms of implementing Rationale. Four high-quality studies,22– 25 6 this recommendation. Benefits are as follows: moderate-quality studies,26–31 and 2 low-quality studies32 ,33 Improved patient adherence examined the effect of CPM use. Findings from 1 Decreased postsurgical complication moderate-quality study31 and 2 low-quality studies32,33 Shortened inpatient length of stay reported some significant statistical effects; however, these findings were contradicted by nonsignificant statistical findings in higher-quality studies.22–25 The outcomes Risk, harm, and/or cost are as follows: measured included knee flexion and extension ROM as well as need for manipulation under anesthesia. No expected risk or harms were associated with this Additionally, meta-analyses for the outcomes of function recommendation. (standardized mean difference [SMD] = 0.14 [−1.10 to There may be an expected associated expense for 0.39])23,24,28 and hospital length of stay (weighted mean the visit. difference [WMD] = −0.15 [−0.60 to 0.30])24,28,29 showed nonsignificant results. Benefit-harm assessment. There is a preponderance of benefit for this recommendation. Potential benefits, risks, and harms of implementing this recommendation. Benefits are as follows: Future research. Additional research on patient preoperative education led by a physical therapist or other Results for outcomes in function were team member is required. This research should evaluate nonsignificant. the method and frequency of the education delivered. In Results for hospital length of stay were addition, outcomes such as patient anxiety, health literacy, nonsignificant. and satisfaction should be considered when evaluating the benefits of preoperative education. Risk, harm, and/or cost are as follows: Value judgments. Although there was not a Bed rest may be prolonged with CPM use. preponderance of high-quality evidence, the GDG felt There is an inconvenience of use. compelled to make a recommendation to support the use Although costs were not reported in studies, there is of preoperative education for patients undergoing TKA. an expected associated expense. Preoperative education was believed to be associated with better postoperative functional outcomes. Benefit-harm assessment: There is a preponderance of evidence to support that there is increased risk, harm, Intentional vagueness. Not applicable. and/or cost related to use of CPM for uncomplicated TKA. 2020 Volume 100 Number 9 Physical Therapy 1611 Total Knee Arthroplasty Future research. Some subpopulations may benefit from from 2 high-quality studies34 ,39 and 2 moderate-quality CPM, and this could be explored with studies large studies40 ,43 found no increased complications between enough to allow subgroup analyses or by narrowing cryotherapy modalities. A meta-analysis of 3 studies36 ,38 ,43 inclusion criteria. Examples may be those with TKA evaluated cryotherapy devices versus standard cold packs revisions or those with particularly poor preoperative for pain management and found no statistically significant ROM. difference. Value judgments. None were identified. Potential benefits, risks, and harms of implementing Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 this recommendation. Benefits are as follows: Intentional vagueness. The nature of an uncomplicated Improvement in pain management. TKA is not explicit in most studies. Only 1 study implied a Low cost and relatively easy application in all definition of uncomplicated by exclusions of patients with “concurrent intervention during surgery that could settings. interfere with outcomes (eg, collateral ligament repair), infection of the affected knee, and any major health Risk, harm, and/or cost are as follows: complication during the hospital stay (eg, pulmonary embolism, heart attack, problems with scar healing).”20 There were no differences in the rate of adverse events reported between a group receiving Exclusions. None were identified. cryotherapy and a control group. There is potential risk of skin irritation, burns, and Quality improvement. When CPM is used, there should frostbite; however, risk or harms are not expected be documented complications associated with TKA that when prescribed and monitored appropriately. justify its use. Appropriately prescribing includes ensuring intact sensation. Implementation and audit. Organizations may audit the use of CPM after TKA and discourage its use unless Benefit-harm assessment: A preponderance of evidence justified by documented complications associated with the supports the use of cryotherapy for pain management. procedure. There were no reported risks or harms to patients using cryotherapy. As with all treatments, it is advised that the patient be instructed on the use of the delivery system (eg, Cryotherapy ♦ cooling devices, ethyl chloride spray, ice packs). Physical therapists should teach and encourage use of Furthermore, the therapist and patient should discuss any cryotherapy for early postoperative pain management for barriers to using cryotherapy (eg, cost, lack of adequate patients who have undergone TKA. Evidence Quality: storage, physical disability) in choosing the appropriate High; Recommendation Strength: Moderate. delivery system. Action Statement Profile Future research. Future research focused on frequency Aggregate evidence quality: 6 high-quality studies34–39 and of use and the length of time cryotherapy is used 4 moderate-quality studies.40–43 postsurgery would further inform use. Rationale. Six high-quality studies34 –39 and 4 moderate-quality studies40–43 examined the use of Value judgments. None were identified. cryotherapy after TKA. One high-quality study37 and 1 low-quality study44 favored cryotherapy over control for Intentional vagueness. Although no one application pain management, and 1 high-quality study found no method was shown to be superior, using cryotherapy is difference. Findings from 1 high-quality study37 found supported in managing postoperative pain. There was not improvement in pain management (VAS pain) with the use sufficient evidence to provide a prescriptive time frame of ethyl chloride spray (applied during exercise for about for the application after surgery. In addition, there was 40 seconds at a distance of about 10 cm) versus controls insufficient evidence to identify how many days 4 weeks after TKA, and 1 high-quality study35 found no postsurgery cryotherapy should be continued. difference at 30 days after TKA in pain management (VAS pain) comparing 45 ◦ F versus 75 ◦ F cryotherapy. One Exclusions. None were identified. low-quality study44 found improved pain (VAS pain) at 30 days after surgery with the use of a continuous-flow cooling device versus no cooling device. One high-quality Quality improvement. Organizations may use study35 and 1 low-quality study44 found no increased documentation of the use of cryotherapy after TKA as a complications with cryotherapy versus controls. Findings performance indicator. 1612 Physical Therapy Volume 100 Number 9 2020  Total Knee Arthroplasty Implementation and audit. Organizations may audit Potential benefits, risks, and harms of implementing occurrence of documentation of use of cryotherapy after this recommendation. Benefits are as follows: TKA to assist in the management of pain. Improved gait function, walking distance, balance, physical function, and health-related quality of life. Improved activities and participation (eg, mobility, Physical Activity ♦♦♦ self-care, domestic life). It is the consensus of the work group that physical therapists should develop an early mobility plan and teach Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 patients who have undergone TKA regarding the Risk, harm, and/or cost are as follows: importance of early mobility and appropriate progression No expected risk or harms are expected when of physical activity, based on safety, functional tolerance, and physiological response. Evidence Quality: progression is monitored and prescribed Insufficient; Recommendation Strength: Best appropriately. Team members should be aware of potential Practice. complications after TKA that may affect exercise including incision healing, thromboembolism, and Action Statement Profile joint stiffness/arthrofibrosis. Aggregate evidence quality: No high-quality studies related to physical activity for patients undergoing TKA. Benefit-harm assessment: There is a preponderance of benefit for this recommendation. Rationale. The GDG members were in consensus with this recommendation that physical activity is an important Future research. Additional research on the effects of aspect in recovery and the progression of activities and progressive physical activity is required. This research participation. The second edition of the US Department of should examine specific regimens or recommendations for Health and Human Services Physical Activity Guidelines physical activity type, frequency, duration, and provides evidence that routine physical activity, including progression and report patient preferences and safety. moderate-to-vigorous aerobic and muscle-strengthening Outcomes related to functions of cardiovascular, exercises, results in substantial health benefits.45 neurological, and musculoskeletal systems as well as The recommendations include weight-bearing exercises patient’s activities and participation should be included. for bone health, balance activities, and flexibility activities. Furthermore, the guidelines note that people with chronic conditions or disabilities (eg, osteoarthritis of the knee Value judgments. Expert opinion and low-quality or TKA) benefit from engaging in physical activity to the evidence support the use of progressive physical activity extent they are able. There is a long list of known health for patients who have undergone TKA for better benefits of physical activity, including lowering risk of postoperative functional outcomes. The individualization all-cause mortality, heart disease and its risk factors, and of physical activity progression with both land-based and certain types of cancer. According to the guidelines, benefits aquatic options to match the patient’s goals, abilities, and of physical activity generally outweigh the risk of injuries. physiological response should include documentation of objective baseline data, the patient’s goals, and plan of One study of physical activity 1 year following TKA care (interventions, dosage, frequency, and duration) as reported that 42% of participants did not meet well as appropriate outcomes to demonstrate patients’ recommendations for levels of physical activity that response to the specific approach. promote health.46 An observational study noted that women who were inactive prior to TKA had increased Intentional vagueness. Not applicable. odds of having mobility limitations and dying by age 85.47 Studies of specific types of exercise regimens (aquatic exercise,48,49 Pilates,50 tai chi chuan51 ) following TKA have Exclusions. None were identified. shown positive effects on a variety of outcomes, including health-related quality of life, walking distance, balance, Quality improvement. Organizations may use the and physical function. One study examining a resistance documentation of plan of care and progression of physical exercise regimen 4 years following TKA demonstrated activity that include items such as patient preferences, benefits of increased strength as well as increased walking safety, functional tolerance, and physiological response as speed and physical function.52 Amount of physical activity a performance indicator. has also been shown to be positively associated with improvements in gait function following TKA.53,54 Implementation and audit. Organizations may audit Furthermore, a dose-response relationship between occurrence of documentation of plan of care and exercise intensity and gait function has been progression of physical activity during the physical demonstrated following TKA.55 therapy visits for patients who undergo TKA. 2020 Volume 100 Number 9 Physical Therapy 1613 Total Knee Arthroplasty Motor Function Training (Balance, Improvement in activities and participation (eg, Walking, Movement Symmetry)  getting in and out of car, shopping, household Physical therapists should include motor function training duties). (eg, balance, walking, movement symmetry) for patients who have undergone TKA. Evidence Quality: High; Risk, harm, and/or cost are as follows: Recommendation Strength: Strong. No expected risk or harms are associated with this recommendation. Action Statement Profile Team members should be aware of potential Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 Aggregate evidence quality: 5 high quality studies56–60 and complications after TKA that may affect exercise 1 moderate quality study.61 including incision healing, thromboembolism, and joint stiffness/arthrofibrosis. Some of the more Rationale. Five high-quality studies56 –60 and 1 advanced training programs that include moderate-quality study61 addressed different aspects of weight-bearing biofeedback or robot-assisted gait movement retraining after TKA. These studies varied in training may be cost- and resource-prohibitive for the types of interventions but included dynamic balance most clinical settings. training,56,59 robot-assisted gait retraining,61 movement training with visual biofeedback to promote Benefit-harm assessment: A preponderance of evidence weight-bearing symmetry,50 or motor functional training.58 supports including motor function training. The individualization of progression to match the patient’s The studies that included balance training56,59 found that goals, abilities, and physiological response should include the balance interventions improved walking function as documentation of objective baseline data, the patient’s measured by gait speed, stair-climbing time, and the TUG goals, and plan of care (interventions, dosage, frequency, test 32 weeks after training59 and by the Six-Minute Walk and duration). This includes the use of appropriate Test 9 months after training.56 Self-reported function was outcomes to demonstrate patient response to the specific also better in the balance groups on the self-efficacy and approach. sports and recreation subscales of the KOOS56 and physical function subscale on the WOMAC.59 Liao also found that balance training improved reaching and Future research. The long-term impact of normalizing single-leg standing tests of balance.59 movement patterns or improving balance after TKA remains unknown. Future research should determine The single study that evaluated 2-week robot-assisted gait whether improving movement symmetry reduces training61 found better outcomes in the experimental long-term sequelae on the surgical and nonsurgical limbs group for balance using the Berg Balance Scale and and whether improving balance after TKA reduces fall walking ability measured with the Six-Minute Walk Test. prevalence and long-term morbidity. As technology Knee proprioception was also better than that of the improves, the use of biofeedback-based movement control group. interventions may become more applicable for this patient population. Future research is warranted to determine the The single study that evaluated feedback on feasibility of such systems and long-term impact. weight-bearing symmetry61 found that subjects in the experimental group had better sagittal plane knee Value judgments. None were identified. moments 26 weeks after surgery and better times for the Five Times Sit-to-Stand Test 6 and 26 weeks after surgery, Intentional vagueness. Given the varied nature of the but no other differences. study interventions, the work group cannot recommend a single postoperative movement training program. The single study that evaluated functional training,60 However, exercises that promote dynamic balance and warm-up exercise, chair rise, walking, and leg lifts while movement symmetry appear to be appropriate. standing did not find any benefit to the functional training protocol, but the retraining was performed in an Exclusions. None were identified. unsupervised home setting, and there was a large loss to follow-up (>50%), and the authors concluded they were Quality improvement. Organizations may use underpowered to detect potential differences. documentation of the use of motor function training (balance, gait, posture) after TKA as a performance Potential benefits, risks, and harms of implementing indicator. this recommendation. Benefits are as follows: Implementation and audit. Organizations may audit Improvement in balance. occurrence of documentation of use of motor function Improvement in walking function. training after a TKA to assist in the management of pain. 1614 Physical Therapy Volume 100 Number 9 2020  Total Knee Arthroplasty Postoperative Knee ROM Exercise ♦♦♦ contribute to successful postoperative outcomes; It is the consensus of the work group that physical therefore, strategies targeting ROM should be therapists should engage and teach patients to implement complemented with other interventions. passive, active assistive, and active ROM exercises for the involved knee following TKA. Evidence Quality: Intentional vagueness. Not applicable. Insufficient; Recommendation Strength: Best Practice. Action Statement Profile Exclusions. None were identified. Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 Aggregate evidence quality: Because ROM exercises are considered a standard of care, there have been no studies Quality improvement. Organizations may use the comparing patients who received ROM exercises to those application of postoperative ROM exercises as a quality who did not. indicator. Rationale. Patients with TKA may have restricted knee Implementation and audit. Organizations may audit the ROM preoperatively associated with loss of elasticity of rate of occurrence of postoperative physical therapy visits the extensor mechanism and capsular structures. that include ROM exercises for patients that receive a TKA. Preoperative knee ROM is positively associated with postoperative knee flexion,62– 64 and patients with severe-to-moderate knee flexion contractures Immediate Postoperative Knee Flexion preoperatively may have a greater risk of postoperative During Rest for Blood Loss and Swelling knee flexion contracture.65 Inadequate knee ROM postoperatively may be associated with worse pain and ♦♦ reduction in Knee Society Score (KSS), walking score, and To reduce immediate postoperative blood loss and stair climbing 3 to 5 years after surgery.66 Physical swelling in the first 7 days after surgery, physical therapists have the skills to work with patients to therapists or other team members may teach patients to encourage movement, including knee ROM to enhance position the operated knee in some degree of flexion patients’ potential to reach full functional mobility. The (30◦ –90◦ ) while resting. Evidence Quality: High; GDG, therefore, were in consensus with this Recommendation Strength: Weak. recommendation. Action Statement Profile Potential benefits, risks, and harms of implementing Aggregate evidence quality: 4 high-quality studies67–70 and this recommendation. Benefits are as follows: 1 moderate-quality71 study. Improved ROM of the knee. Decreased postsurgical complication. Rationale. Four high-quality studies67– 70 and 1 Improved functional outcomes. moderate-quality71 study evaluated knee positioning during the immediate postoperative period and its effect on blood loss, swelling, edema management, and ROM. Risk, harm, and/or cost are as follows: One high-quality study68 found decreased knee blood loss No expected risk or harms were associated with this and knee circumference and improved knee flexion ROM recommendation. when comparing the resting position of 30 degrees of hip Team members should be aware of potential flexion and 30 degrees of knee flexion with 30 degrees of complications after TKA that may affect exercise hip flexion and full knee extension at 3 and 7 days after including incision healing, thromboembolism, and TKA. The study did not indicate if ROM was measured joint stiffness/arthrofibrosis. passively or actively, and extension ROM was not measured. There was no difference between groups in flexion ROM at 6 weeks. Benefit-harm assessment: There is a preponderance of benefit for this recommendation. One high-quality study67 found decreased knee blood loss and circumference when comparing mild flexion (leg Future research. Additional research is not anticipated elevated 25 cm at the ankle over a backing pad, with a given that a true control group without ROM exercise is 20-cm backing pad set behind the upper calf to bend the unlikely to be approved in any trial. knee mildly) with extension (leg elevated 25 cm at the ankle over a backing pad with full extension of the knee) Value judgments. Despite a lack of high-quality at 7 days after surgery. The knee positioned in mild evidence, the GDG felt compelled to make a strong flexion, from postoperative days 1 through 7, had greater recommendation to support the use of ROM exercises. venous return, less postoperative blood loss and knee However, other factors besides ROM substantially swelling, and greater knee flexion ROM. There were no 2020 Volume 100 Number 9 Physical Therapy 1615 Total Knee Arthroplasty differences in knee flexion ROM at 6 weeks’ follow-up. Benefit-harm assessment: There is benefit in reducing Extension ROM was not measured. blood loss and swelling in the first 7 days postsurgery. Improved flexion ROM is not long term, with only 1 study One high-quality study69 found decreased blood loss and showing improvement after 6 weeks and none after knee circumference at 7 days after surgery in a group of 6 months. The impact on extension ROM is not known. patients with the knee positioned in 45 degrees of hip Most of these studies had a length of stay greater than flexion and 90 degrees of knee flexion when compared 7 days or the length of stay was unreported. There is a with a second group with the knee positioned in full question about the generalizability of the results of these Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 extension. These positions were maintained for the first studies to postoperative care due to the length of stay. For 6 hours postoperatively. There were no statistical these reasons, the strength of this recommendation is weak. differences in knee flexion ROM at 7 days between groups. Extension ROM was not measured. Future research. Continued comparative studies that have larger sample sizes and compare positioning the One high-quality study70 compared patients with the knee knee at different degrees of flexion during the immediate positioned in 60 degrees of hip flexion and 60 degrees of postoperative period after TKA may further clarify the use knee flexion with a group of patients positioned in full of this approach to minimize swelling and edema. knee extension. These positions were maintained for the Furthermore, the optimal degrees of flexion are still to be first 48 hours after surgery. The results showed decreased determined, as is the minimal timing required to obtain blood loss, shorter hospital length of stay by 1.9 days, the reported effect. Future studies should include decreased knee circumference, and greater flexion ROM at outcomes related to knee extension rom. 6 weeks postsurgery (105 degrees vs 98 degrees) in the group with the knee resting in flexion. Overall length of Value judgments. Given the potential for short term stay for both groups averaged over 10 days in these reduced blood loss and swelling, the work group Chinese hospitals. There were no differences in knee recommend knee flexion during rest immediately flexion ROM at 6 months follow-up. postsurgery. One moderate-quality study71 found no difference in knee blood loss, circumference, or flexion ROM when Intentional vagueness. Given the varied nature of the comparing high flexion (70 degrees) to mild flexion (30 study interventions, the work group cannot recommend a degrees) at 7 days after surgery. The mean length of stay specific length of time or degree of flexion after the in this Italian hospital was 8 days. surgery; however, most studies looked at a time frame of 7 days and knee flexion between 30 and 90 degrees. It These findings further support the meta-analysis by Jiang was unclear the amount of time per day that the knee was et al72 that assessed the impact of flexion versus extension in flexion. of knee position on outcomes after TKA. This later study concluded that positioning the knee in flexion in the early Exclusions. None were identified. postoperative stage was associated with significantly less total calculated blood loss, less hidden blood loss, Quality improvement. Organizations may use decreased requirement for blood transfusion, and better documentation of patient and/or caregiver education for ROM at least in the early postoperative period, which patient resting knee flexion for the immediate may contribute to early rehabilitation. Importantly, postoperative period after TKA as a performance indicator no significant difference was found in ROM at of reduced blood loss and swelling. 6 weeks. Implementation and audit. Organizations may audit Potential benefits, risks, and harms of implementing occurrence of documentation of patient and/or caregiver this recommendation. Benefits are as follows: education for patient resting knee flexion for the Decrease in blood loss associated with TKA surgery. immediate postoperative period after a TKA to assist in Decrease in swelling in the first 7 days postsurgery. the management of blood loss and swelling. Improvement in short term flexion ROM. Neuromuscular Electrical Stimulation Risk, harm, and/or cost are as follows: There is a potential (NMES) ♦ risk of developing limited extension ROM with this Physical therapists should use NMES for patients who recommendation. Knee extension ROM was not measured have undergone TKA to improve quadriceps strength, gait in these studies. Limited knee extension could be a risk performance, performance-based outcomes, and factor with patients being placed in a knee flexion resting patient-reported outcomes. Evidence Quality: High; position postoperatively. Recommendation Strength: Moderate. 1616 Physical Therapy Volume 100 Number 9 2020  Total Knee Arthroplasty Action Statement Profile optimal outcomes; however, preoperative education Aggregate evidence quality: 4 high-quality studies73– 76 and improves the quality of implementation. 1 moderate-quality77 study. Intentional vagueness. Given the varied nature of the Rationale. Four high-quality studies73–76 and 1 study interventions, the work group cannot recommend a moderate-quality77 study compared the use of specific setting for NMES; however, studies consistently neuromuscular electrical stimulation (NMES) with no used parameters that allowed for tetanic quadriceps NMES use in the treatment of patients after TKA. Two muscle contractions with stronger contractions leading to Downloaded from https://academic.oup.com/ptj/article/100/9/1603/5857258 by APTA Member Access user on 20 January 2025 high quality studies75,76 found that NMES improved greater quadriceps strength. quadriceps and hamstring muscle maximum voluntary isometric contractions from 2 to 52 weeks after TKA. Four high-quality studies73– 76 reported greater improvement in Exclusions. None were identified. walking, stair-climbing performance, and patient-reported outcomes with NMES use compared with no NMES from 2 Quality improvement. Organizations may use to 52 weeks after TKA. Postoperative ROM with NMES use documentation of use of NMES after TKA as a was not different from no NMES use from 2 to 52 weeks performance indicator. after TKA.75– 77 Earlier NMES (as early as postoperative day 2) and more frequent (5–7 times daily) application with longer cumulative time at the maximal intensity tolerated Implementation and audit. Audits of occurrence of by patients improved outcomes.73– 76 Patients after TKA documentation of use of NMES after a TKA to assist with who would most likely benefit are those with quadriceps isometric contractions of the quadriceps and hamstrings muscle activation deficits, often measured in terms of a may be used. quadriceps extensor lag or quadriceps activation battery. NMES should be applied for at least a minimum of 3 weeks. Resistance and Intensity of Strengthening Exercise ♦ Potential benefits, risks, and harms of implementing Physical therapists should design, implement, teach, and this recommendation. Benefits are as follows: progress patients who have undergone TKA in high-intensity strength training and exercise programs Improvement in quadriceps and hamstrings during the early postacute period (ie, within 7 days after maximum voluntary isometric contractions from 2 surgery) to improve function, strength, and ROM. Evidence to 52 weeks after TKA. Quality: High; Recommendation Strength: Moderate. Improvement in walking, stair-climbing performance, and patient-reported outcomes. Action Statement Profile Aggregate evidence quality: 3 high-quality studies11,78,79 Risk, harm, and/or cost are as follows: and 1 moderate-quality study.80 The financial cost of using NMES and its availability to patients may be prohibitive for patients. Rationale. Three high-quality studies11,78,79 and 1 Pain/discomfort with use. moderate-quality study80 support the benefits of Decreased tolerance. land-based, high-intensity resistance training based on patient tolerance, muscle function, functional performance, and balance. Evgeniadis11 found that Benefit-Harm Assessment: There is a preponderance of postoperative resistance training (8 weeks) resulted in benefit for this recommendation. higher levels of functional mobility and better knee extension ROM. Future research. Although current evidence supports the use of NMES after TKA, additional research might One additional high-quality study evaluated the safety of continue to refine NMES benefits by understanding the early high-intensity resistance training using specified best patient factors for NMES use, optimal dosage, progression criteria78 on knee ROM and adverse events stimulation parameters, application with and without and found that early high-intensity resistance training is as concurrent muscle contraction, mechanisms explaining safe as low-intensity resistance training. Knee ROM NMES efficacy, adjuncts to NMES (eg, nutritional (flexion or extension) was not compromised with early supplementation), and when to discontinue NMES. high-intensity resistance training initiated 72 hours after TKA. The study did not find improvements in muscle Value judgments. Independent application (placement) strength or physical function, but both groups of electrodes and inappropriate implementation of the demonstrated substantially better outcomes than have parameters of NMES by the patient may lead to less been previously reported. In particular, the control group 2020