Rehabilitation for Total Knee Arthroplasty: A Systematic Review

Abstract

We sought to determine the comparative benefit and harm of rehabilitation interventions for patients who have undergone elective, unilateral total knee arthroplasty for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Register of Clinical Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We included randomized controlled trials and adequately adjusted nonrandomized comparative studies of rehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. The team assessed strength of evidence. Evidence from 53 studies randomized controlled trials suggests that various rehabilitation programs after total knee arthroplasty may lead to comparable improvements in pain, range of motion, and activities of daily living. Rehabilitation in the acute phase may lead to increased strength but result in similar strength when delivered in the postacute phase. No studies reported evidence of risk of harms due to rehabilitation delivered in the acute period after total knee arthroplasty; risk of harms among various postacute rehabilitation programs seems comparable. All findings were of low strength of evidence. Evaluation of rehabilitation after total knee arthroplasty needs a systematic overhaul to sufficiently guide future practice or research including the use of standardized intervention components and core outcomes.

Figure 1.. Overview of studies of rehabilitation compared to various controls for total knee arthroplasty

Figure presents categorization of studies (n=21) that evaluated acute rehabilitation programs TKA. The first column lists novel (more intensive) programs compared with different programs (first group hypothesized to be better); the second column lists studies with comparatively similar rehabilitation programs in both arms that were delivered with different timing or intensity (first group hypothesized to be better); the third column lists studies with comparatively similar rehabilitation programs delivered in different settings or by different personnel (i.e., shift in resources providing care; groups hypothesized to be comparable); the fourth column lists studies with rehabilitation interventions comparing a rehabilitation program and an adjunctive modality vs. the same rehabilitation program alone (first group hypothesized to be better). Studies are defined using arm descriptors first and component coding second. The different colors are added to visually separate the columns and do not provide unique information. Abbreviations: Adj = adjunctive, A = aerobic exercise, B= balance-motor/learning-agility exercise, E = patient education, F = flexibility exercise, NMES = neuromuscular electrical stimulation, S = strengthening exercise, T = task-specific training. * Intervention included progression which was deemed appropriate.

Figure 2.. Goal components strength, aerobic, and flexibility and their specific exercise components for acute-rehabilitation intervention versus various controls for total knee arthroplasty

See Figure 3 for goal components balance-motor-learning-agility, task specific training, patient education, and adjunctive modalities. Abbreviations: AT = aquatic therapy, CH = community hospital, ex = exercise, GT = gait training, H = home, HTS = hybrid training system, IF = inpatient facility, LTC = long term care facility, OCA = open chain ankle, UP = upper extremity, physio = physiotherapy, rehab = rehabilitation, ROM = range of motion, TKE = terminal knee extension A Novel rehabilitation vs. standard care/other rehabilitation B Similar rehabilitation with varying intensity/timing C Similar rehabilitation delivered in different setting/by different personnel D Similar rehabilitation with/without adjuvant modality

Figure 3.. Goal components balance-motor-learning-agility, task specific training, patient education, and adjunctive modalities and their specific exercise components for acute-rehabilitation intervention versus various controls for total knee arthroplasty]

See Figure 2 for goal components strength, aerobic, and flexibility. The color is added for visual display and does not provide unique information. Abbreviations: AI = acute inpatient, AT = aquatic therapy, CAM = complementary and alternative therapies, GT = gait training, H = home, HTS = hybrid training system, I = in-person; inpt = inpatient, IF = inpatient facility, LTC = long term care facility, MSAR = mindfulness, stress/anxiety reduction, NA = not applicable, NMES = neuromuscular electrical stimulation, O = outpatient physiotherapy center, OIF = other inpatient facility, PRT = progressive resistive training; preop = preoperative; PT = physical therapist, R = remote, tele = telephone, TENS = transcutaneous electrical nerve stimulation, rehab = rehabilitation, SG = self-guided A Novel rehabilitation vs. standard care/other rehabilitation B Similar rehabilitation with varying intensity/timing C Similar rehabilitation delivered in different setting/by different personnel D Similar rehabilitation with/without adjuvant modality E Pool F Remote via app or telephone G Research personnel

Figure 4.. Overview of studies of post-acute phase rehabilitation interventions for total knee arthroplasty

Figure presents categorization of studies (n=32) that evaluated post rehabilitation programs for TKA. The first column lists a novel (more intensive) program compared to a different program (first group hypothesized to be better); the second column lists a single study comparing two different rehabilitation programs hypothesized to be equivalent; the third column lists a single study with comparatively similar rehabilitation programs in both arms that were delivered with different timing or intensity (first group hypothesized to be better); the fourth column lists studies with comparatively similar rehabilitation programs delivered in different settings or by different personnel (i.e., shift in resources providing care; groups hypothesized to be comparable); the fifth column lists studies with rehabilitation interventions comparing a rehabilitation program and an adjunctive modality vs. the same rehabilitation program alone (first group hypothesized to be better). Studies are defined using arm descriptors first and component coding second. The different colors are added to visually separate the columns and do not provide unique information. Abbreviations: Adj = adjunctive, A = aerobic exercise, B= balance-motor/learning-agility exercise, E = patient education, F = flexibility exercise, S = strengthening exercise, T = task-specific training. * Intervention included progression which was deemed appropriate

Figure 5.. Goal components strength, aerobic, and flexibility and their specific exercise components for post-acute-rehabilitation interventions (part 1) versus various controls for total knee arthroplasty

This figure represents the first half of the studies assessing post-acute rehabilitation interventions (part 1). All studies in this figure assessed novel interventions hypothesized to improve effects compared with controls. See Figures 7 and 8 for remainder of the studies assessing post-acute rehabilitation interventions (part 2). See Figure 6 for goal components balance-motor-learning-agility, task specific training, patient education, and adjunctive modalities for part 1 studies. The color is added for visual display and does not provide unique information. Abbreviations. BT = balance training, CBI = comprehensive behavioral intervention, ed = education, ex = exercise, fxn = function, fxtl = functional, FSET = focal sensorimotor exercise training, grp = group, HAT = hip abduction training, HI = high intensity, LI = low intensity, O = outpatient, PA = physical activity, physio = physiotherapy, rehab = rehabilitation, ROM = range of motion, TKE = terminal knee extension

Figure 6.. Goal components balance-motor-learning-agility, task specific training, patient education, and adjunctive modalities and their specific exercise components for post-acute-rehabilitation interventions (part 1) versus various controls for total knee arthroplasty

This figure represents the first half of the studies assessing post-acute rehabilitation interventions (part 1). All studies in this figure assessed novel interventions hypothesized to improve effects compared with controls. See Figures 7 and 8 for remainder of the studies assessing post-acute rehabilitation interventions (part 2). See Figure 5 for goal components strength, aerobic, and flexibility for part 1 studies. The color is added for visual display and does not provide unique information. The color is added for visual display and does not provide unique information. Abbreviations: AI = acute in-patient; BT = balance training, CBI = comprehensive behavioral intervention, ex = exercise, fxn = function, fxtl = functional,, FSET = focal sensorimotor exercise training, grp = group, HAT = hip abduction training, HI = high intensity, H = home, I = in-person, G = gym/other community center, NA = not applicable, NMES = neuromuscular electrical stimulation, NR = not reported, O = outpatient physiotherapy center; OIF = other inpatient facility, PENS = patterned electrical neuromuscular stimulation, PT = physical therapist R = remote; rehab = rehabilitation; SG = self-guided; tele = telephone; TENS = transcutaneous electrical nerve stimulation, video = videoconference A Psychologist B Remote via telephone

Figure 7.. Goal components strength, aerobic, and flexibility and their specific exercise components for post-acute-rehabilitation interventions (part 2) versus various controls for total knee arthroplasty

This figure represents the second half of the studies assessing post-acute rehabilitation interventions (part 2). See Figures 5 and 6 for first half of the studies assessing post-acute rehabilitation interventions (part 1). See Figure 8 for goal components balance-motor-learning-agility, task specific training, patient education, and adjunctive modalities for part 2 studies. Abbreviations: NMES = neuromuscular electrical stimulation, rehab = rehabilitation, ROM = range of motion, PT = physiotherapy, TKE = terminal knee extension. A Different rehabilitation program (hypothesized similar) B Similar rehabilitation with varying intensity/timing C Similar rehabilitation delivered in different setting/by different personnel D Similar rehabilitation with/without adjuvant modality

Figure 8.. Goal components balance-motor-learning-agility, task specific training, patient education, and adjunctive modalities and their specific exercise components for post-acute-rehabilitation interventions (part 2) versus various controls for total knee arthroplasty

This figure represents the second half of the studies assessing post-acute rehabilitation interventions (part 2). See Figures 5 and 6 for first half of the studies assessing post-acute rehabilitation interventions (part 1). See Figure 7 for goal components balance-motor-learning-agility, task specific training, patient education, and adjunctive modalities for part 2 studies. The color is added for visual display and does not provide unique information. Abbreviations: AI = acute in-patient; CAM = complementary and alternative therapies, I = in-person; G = gym/other community center; H = home; NA = not applicable, NR = not reported, NMES = neuromuscular electrical stimulation, O = outpatient physiotherapy center, OIF = other inpatient facility, PT = physical therapist, R = remote; rehab = rehabilitation, SG = self-guided; tele = telephone; TENS = transcutaneous electrical nerve stimulation. A Different rehabilitation program (hypothesized similar) B Similar rehabilitation with varying intensity/timing C Similar rehabilitation delivered in different setting/by different personnel D Similar rehabilitation with/without adjuvant modality E Remote via video F Remote via video G Athletic trainer H Tai Chi instructors