Total Knee Replacement - Physiotherapy Management

Introduction

Maintaining a complete recovery following total knee replacement involves incorporating regular exercise to rebuild strength and mobility in the knee, alongside gradually reintegrating into daily routines. Orthopedic surgeons and physical therapists may advise dedicating 20 to 30 minutes to exercise daily, or even multiple times throughout the day, and engaging in 30-minute walks two to three times daily during the initial stages of recovery. This article aims to clarify the exercise regimen and activity plan overseen by physical therapists and orthopedic surgeons. To prioritize safety during recovery, always consult with therapists or surgeons before attempting any of the exercises outlined.

What Is Knee Replacement Surgery?

Knee replacement surgery, typically known as total knee arthroplasty (TKA), is a medical approach to replace a damaged knee joint with an artificial one. This surgery is typically recommended for individuals experiencing severe knee pain or impaired mobility due to osteoarthritis (cartilage wears down over time, causing joint pain and stiffness), rheumatoid arthritis (immune system attacks joint lining, leading to inflammation and damage), or traumatic injury. During the procedure, the surgeon removes the damaged knee parts and puts in new artificial metal, plastic, or ceramic pieces. Knee replacement surgery intends to ease pain, regain movement, and enhance the patient's overall quality of life.

How Does Physiotherapy Help After a Knee Replacement Surgery?

Physiotherapy aids recovery post-total knee replacement by enhancing mobility, strengthening muscles, reducing pain, and improving overall function. Physical activity is not just beneficial; it is a crucial part of the recovery journey after TKA. It is about improving overall health and reducing the risk of heart disease, cancer, and mortality (death). Surprisingly, many TKA patients do not meet the recommended physical activity levels. But here is the good news- various exercises, like aquatic exercise, Pilates (exercise that emphasizes core strength and controlled movements), and tai chi (exercise that focuses on slow, flowing movements and relaxation), can significantly improve the quality of life, balance, and physical function after TKA. The intensity and duration of the exercise contribute to improving walking ability.

• Potential Benefits:

  • Improved walking ability, balance, physical function, and quality of life.

  • Better performance in daily activities like walking and self-care.

• Risks and Considerations:

  • There are no significant risks when exercise is monitored and adjusted correctly.

  • Patients should know potential complications post-TKA, such as incision healing issues, blood clots, and joint stiffness.

• Future Research:

  • More research is needed to understand the effects of different types, frequencies, durations, and progressions of physical activity after TKA.

  • Studies should focus on various outcomes related to cardiovascular, neurological, and musculoskeletal function and patients' abilities to perform daily activities.

Physiotherapy can be done in the following phases:

• Pre-Surgical Physiotherapy: Before TKA surgery, patients may undergo pre-surgical rehabilitation exercises to prepare them for post-surgical recovery. These exercises focus on improving postural control, functional lower limb movements, and bilateral lower extremity strength. However, evidence supporting the effectiveness of pre-surgical physiotherapy on patient outcomes, lower limb strength, pain, range of movement, or hospital length of stay after TKA is limited.

• Post-TKA Surgery: After TKA surgery, which typically lasts one to two hours, most patients start physiotherapy within 24 hours of surgery. This includes range-of-motion exercises, strengthening exercises, cryotherapy, and gait training. A home exercise program is usually prescribed before discharge from the hospital. Some evidence suggests that accelerated physiotherapy regimens can shorten the hospital stay.

Patients are usually discharged from the hospital after a few days and receive follow-up physiotherapy within a week of discharge, either in an outpatient clinic or at home.

• Post-Surgical Physiotherapy: Physiotherapy interventions have improved physical function, range of motion, and pain in the short term following TKA. However, the long-term benefits and cost-effectiveness of these interventions require further study.

What Are the Exercise Plan and Objectives for Post-surgical Physiotherapy?

The post-surgical physiotherapy exercise plan and objectives are:

1. Phase I (Up to Two to Three Weeks Post-surgery):

• Educate patients on managing pain and the significance of home exercises.

• Attain 90-degree knee flexion and full extension.

• Reduce pain and swelling.

• Achieve full weight bearing and independence in daily activities.

• Review and reinforce the home exercise program, emphasizing safe movements and avoiding knee pillow use.

Common Bed and Chair Exercises:

• Ankle Plantar Flexion or Dorsiflexion: Move the foot up and down rhythmically.

• Inner Range Quadriceps Strengthening: Use a pillow or rolled towel behind the knee to contract the quadriceps.

• Isometric Knee Extension: Push the knee down into the bed.

• Knee and Hip Flexion or Extension: Bend and straighten the knee and hip.

• Straight Leg Raises: Lift the leg while keeping it straight.

• Isometric Buttock Contraction: Squeeze the buttocks together.

• Hip Abduction or Adduction: Move the leg to the side and back.

• Bridging: Lift the buttocks off the bed while keeping the back straight.

2. Phase II (Four to Six Weeks Post-surgery):

• Ensure reasonable quadriceps muscle control.

• Achieve 105-degree knee flexion and full extension.

• Continue to manage pain and swelling.

• Increase physiotherapy sessions for progressive exercises and improving scar mobility.

3. Phase III (Six to Eight Weeks Post-surgery):

• Focus on strengthening, functional movements, balance, and proprioception training.

• Perform single-leg balancing, stepping over objects, lateral step-ups, and standing on uneven surfaces.

• Start balance and proprioceptive training involving single-limb standing once adequate knee control is achieved.

4. Phase IV (Eight to Twelve Weeks to One Year Post-surgery):

• Aim for independent exercise in the community.

• Maintain regular exercises for strength, balance, and proprioception.

• Implement strategies for behavior change to sustain overall physical activity levels.

Advanced Exercises and Activities:

• Standing Knee Bends: Lift thigh, bend knee, hold, then straighten. Repeat for two minutes.

• Assisted Knee Bends: Lie down and use a towel to bend the knee. Repeat for two minutes.

• Knee Exercises with Resistance: Add ankle weights, start light, and increase gradually.

• Exercycling: Start slowly, pedal backward first, then forward. Increase duration and tension gradually.

What Should One Take Care of While Exercising?

When exercising after knee replacement surgery, it is essential to:

• Follow the physiotherapist's instructions carefully.

• Begin with mild exercises and progressively raise the intensity.

• Avoid high-impact activities that strain the knee.

• Employ correct form and technique to avoid injury.

• Pay attention to the body's signals and cease activity if any pain or discomfort.

• Stay hydrated and take breaks as needed.

• Wear appropriate footwear and supportive gear.

• Communicate any concerns or difficulties with the physiotherapist.

Conclusion

Total knee replacement (TKR), accompanied by comprehensive physiotherapy management, marks a significant milestone in patients' journey towards restored function and mobility. Physiotherapy is pivotal in optimizing post-operative outcomes by enhancing strength, flexibility, and range of motion while minimizing pain and discomfort. Through a structured rehabilitation program, patients undergo a gradual progression of exercises and activities tailored to their needs and capabilities. This systematic approach promotes physical healing and fosters confidence and stability in facing recovery challenges. Moreover, collaborative efforts between patients and physiotherapists create a supportive environment conducive to achieving rehabilitation goals. Frequent monitoring and modifications to the treatment regimen ensure steady and sustainable progress, empowering patients to participate actively in their recovery journey.