Total Knee Arthroplasty: An Inpatient Physical Therapy Program Using Therapeutic Exercise
Amy Staples
Introduction
Total knee arthroplasty (TKA) is a procedure that can help relieve pain and restore function in
severely diseased knee joints. According to the CDC there were 719,000 performed in 2010 (1).
This surgery is usually performed in patients with severe arthritis or severe knee injury.
The complication rate following total knee replacement is low. Serious complications, such as a
knee joint infection, occur in fewer than 2% of patients. Major medical complications such as
heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for
complications. Although uncommon, when these complications occur, they can prolong or limit
full recovery (2). Studies show that waiting until the pain and loss of function are substantial can
make joint surgery more difficult and reduce the chance of regaining good function.
In this procedure, the entire diseased or damaged knee joint is removed and replaced with an
artificial one (prosthesis). The first artificial knees were a little more than basic hinges. Now,
there are a variety of choices to choose from that take into account the age, weight, activity level
and overall health. The newest models of knee replacements attempt to imitate the knee's natural
ability to roll and glide as it bends.
Physical therapy after surgery during the acute and sub-acute phases is an essential element of
recovery for a patient with a total knee arthroplasty. Initiation of rehabilitation within 24 hours
after total knee arthroplasty reduces the mean hospital stay and number of sessions required to
achieve independence and normal gait and balance (3). Physical Therapy addresses gait and stair
training, muscle strengthening, range of motion exercises and safety precautions.
The purpose of this case study is to describe an inpatient physical therapy plan of care for a
patient who had a total knee arthroplasty.
Case Description
Patient
The patient was a 65 year old female who had severe osteoarthritis in both knees. The patient
elected to undergo bilateral total knee arthroplasty. The patient lived at home with her spouse.
The patient’s home has multiple floors with stairs and handrails on both sides. The patient stated
that she was independent in all activities of daily living and driving. The patient did not
previously use an assistive device. Her past medical history included urinary incontinence,
hypothyroid and osteoarthritis. The patient was cleared by the surgeon for weight-bearing as
tolerated in both lower extremities for all activities.
Examination
The following examination was performed by the physical therapist within 24 hours of being
admitted to the joint and spine floor following the initial surgery.
Posture
Sitting Balance
Standing Balance
Range of Motion
Strength
Gait
Sensation
Pain
Incision
Cognition
Bed Mobility
Transfers
Endurance
Forward Flexed
Good
Fair
Right Lower Extremity: Active Assisted Range of Motion in supine: 6-92°
Left Lower Extremity: Active Assisted Range of Motion in supine 8-65°
Right Lower Extremity: Quad: 3/5, Ankle/Hip: 4/5.
Left Lower Extremity: Quad:3/5, Ankle/Hip 4/5
Distance 70 ft. antalgic, bilateral flexed knee gait. Distance limited by Pain.
Assistance: Minimal, verbal cueing. Equipment: Forward Wheeled Walker,
Gait Belt
Grossly intact. No deficits.
6 out of 0/10 scale
Dressing clean and intact. Drain in situ and appears intact.
Patient was fully awake and oriented
Supine to sit: Stand by assistance (SBA) with verbal cueing
Sit to stand: minimum assistance with verbal cueing
fair
Interventions
After examining the patient, the patient and physical therapist discussed therapy and patient
goals. The following short-term goals were set and agreed upon by both the therapist and patient.
Discharge/Short term goals: To be met in 3 days
1.
2.
3.
4.
5.
Patient will be independent in bed mobility.
Patient will transfer sit to stand with modified independence (forward wheeled walker)
Patient will ambulate 400 feet with modified independence (forward wheeled walker)
Patient and family will be independent with written home exercise program.
Patient will have 0 degrees of Extension to 100 degrees of Flexion range of motion
(ROM) of bilateral knees.
6. Patient will ascend and descend 10 stairs with use of handrails on both sides.
The patient was admitted to the joint and spine acute care unit after recovery from surgery. The
patient’s physical therapy sessions were twice daily for twenty to thirty minutes each day (stayed
for 3 days). The initial plan of treatment set by the physical therapist consisted of gait training,
transfer training, bed mobility training, therapeutic exercises, range of motion (ROM) exercises,
stair training, patient/family education, and discharge planning.
Gait training
Gait training was performed initially with a forward wheeled walker (FWW), with the patient
weight-bearing as tolerated through lower extremities (LE). Patient was allowed standing rest
breaks as required. Gait training distance began at 50 feet, with minimum assistance and verbal
cues. Verbal cues were given for step-through pattern sequencing, upright posture, proper use of
a forward wheeled walker, knee extension was stance phase and knee flexion during swing
phase. As the patient’s activity tolerance improved, gait distance was increased and few rest
breaks were taken. On day 3 the patient was able to ambulate with modified independence using
a forward wheeled walker 400 feet.
Transfer Training
Transfer training involved supine to sit, and sit to stand from various surfaces. The patient
initially required minimum assistance for transfers. A pre-bed mobility exercise of lower trunk
rotation in hooklying position was used. Sequencing and safety were taught to the patient; this
was followed by demonstration and verbal cueing. The training was progressed by removing bed
rails, decreased bed/chair height and decreasing assistance from the therapist.
Therapeutic exercise
Patient was given a written exercise sheet with the evaluation. Exercises were also demonstrated
by the physical therapist assistant prior to patient initiation and verbal cues for correct execution
were given as the patient performed the exercises. The following table delineates what
therapeutic exercises were performed, how many repetitions and how often.
Day 1: Bilateral Lower
Extremities – 2 x daily
(evaluation was 1 time)
Ankle pumps x 10 each
Heel slides x 10
Quad sets x 10 each
Gluteal squeezes x 10
Short Arc Quads x 10
Hip ABD/ADD x 10
Long arc Quads x 10
Seated knee flexion
Gait training w/FWW 70 ft
Day 2: Bilateral Lower
Extremities – 2 x daily
Day 3: Bilateral Lower
Extremities – 2 x daily
Quad sets x 10 each
Gluteal squeezes x 10
Short Arc Quads x 10
Hip ABD/ADD x 10
Seated Marching x 10
Long arc Quad x 10
Straight Leg Raise x 10
Gait training w/FWW 200 feet
Stair training x 5 stairs
Quad sets x 10 each
Gluteal squeezes x 10
Short Arc Quads x 10
Hip ABD/ADD x 10
Seated Marching x 10
Long arc Quad x 10
Straight Leg Raise x 10
Gait training w/FWW 400 feet
Stair training x 10 stairs
Stair Training
The patient was instructed to ascend stairs leading with the lower extremity that felt stronger (left
side). To descend the stairs the patient was instructed to lead with the weaker lower extremity
(right side).
The following sequence was used for stair training:
1. Ascend/descend 4” stairs with bilateral handrails
2. Ascend/descend 6” stairs with bilateral handrails
3. Ascend/descend 4” stairs with one handrail
4. Ascend/descend 6” stairs with one handrail
Patient/Family Education
The patient was educated on gait safety, stair safety, and transfer safety. A written handout
outlining a home exercise program was given and demonstrated to the patient. The patient then
demonstrated the exercises to express her understanding. The patient was educated on home
safety, including continued use of forward wheeled walker until surgeon or home health physical
therapist progresses her to a single point cane or no assistive device.
Outcomes
The following table outlines the patient’s status at time of discharge. The patient was discharged
to home with instructions to use the FWW for ambulation, transfer and standing activities until
cleared for further progress by home health physical therapist or surgeon.
Note: strength and activity tolerance were not formally assessed; the patient’s ability to perform
exercises or do functional activities have been used in place of these
Posture
Sitting Balance
Standing Balance
Range of Motion
Strength
Gait
Sensation
Pain
Incision
Cognition
Bed Mobility
Transfers
Endurance
Forward Flexed
Good
Fair +
Right Lower Extremity: Active Assisted Range of Motion in supine: 0-115°
Left Lower Extremity: Active Assisted Range of Motion in supine 0-110°
Right Lower Extremity: Quad: 4+/5, Ankle/Hip: 4+/5.
Left Lower Extremity: Quad:4/5, Ankle/Hip 4/5
Distance 400 ft. antalgic. Distance limited by pain. Assistance: Stand by
Assist Equipment: Forward Wheeled Walker, Gait Belt
Grossly intact
5 out of 0/10 scale
Dressing clean & intact.
Patient was fully awake and oriented
Supine to sit: Independent
Sit to stand: Modified Independent with forward wheeled walker
fair
Discussion
The goals of physical therapy interventions during the early post-operative phase is to decrease
swelling, increase range of motion, enhance muscle control and strength in the involved lower
extremity and maximize patients’ mobility. The average length of hospital stay after a total knee
arthroplasty is 4 days (6).
After a total knee arthroplasty procedure, patients have decreased lower extremity strength and
functional performance compared with age-matched controls (5, 7, 8). Physical therapy is vital
in improving strength and functional abilities. Recent research states that early, more intense
physical therapy rehabilitation results in improved lower extremity strength and functional
outcomes (3, 4, 5, 7). During the hospital stay physical therapy is focused on accomplishing the
short term goals set by the Physical Therapist. Continuing physical therapy after a patient’s
hospital stay is important to reach long term improvements and functional goals (4, 5, 7, 8).
Most surgeons advise against high-impact activities such as running, jogging, jumping, or other
high-impact sports for the rest of your life after surgery. Realistic activities following total knee
replacement include unlimited walking, swimming, golf, driving, light hiking, biking, ballroom
dancing, and other low-impact sports. With appropriate activity modification, knee replacements
can last for many years (2).
Through physical therapy, the patient in this case report gained the following abilities during her
three day hospital stay:
1. Independent in bed mobility.
2. Transfer sit to stand with modified independence (forward wheeled walker)
3. Ambulate 400 feet with modified independence (forward wheeled walker)
4. Independent with written home exercise program.
5. Achieved 0 degrees of Extension to 100 degrees (115 degrees on right) of flexion range
of motion of bilateral knees.
6. Ascend and descend 10 stairs with the use of one handrail.
Conclusion
Total knee arthroplasties have become more prevalent in recent years. The total knee arthroplasty
reliably reduces pain and improves self-reported function in most patients. To be able to enjoy all
of the benefits of a total knee arthroplasty, it is important to start physical therapy early and
continue until strength and functional goals have been reached.
References
1. National Center for Health Statistics, NCHS on Inpatient Procedures, Retrieved October
25, 2014, from http://www.cdc.gov/nchs/fastats/inpatient-surgery.htm
2. American Academy of Orthopedic Surgeons, Retrieved October 25, 2014, from
http://orthoinfo.aaos.org/topic.cfm?topic=a00389
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knee arthroplasty: an update on rehabilitation practices. Current Opinion in
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pathway can reduce length of stay after total knee arthroplasty. Hospital for Special
Surgery Journal. 2011; 7(1):9-15.
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