A Total Knee Arthroplasty: An Inpatient Physical Therapy Program Using Therapeutic
Exercise
Jennifer Lima
Introduction
Total knee arthroplasty also known as TKA is a procedure that is very common and
increasing in our day, and with out current technology. According to the CDC 719,000
TKA procedures were performed in 2010. (1) The most common cause or need for a TKA
is arthritis, including osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis.
Osteoarthritis being the leading cause, there are other reasons for replacement
including fractures, torn cartilage, torn ligaments, or any other irreversible damage done
to the knee joint. (4)
Complications may occur with any surgical procedure, some possible complications of
the TKA may include, but are not limited to, the following: bleeding, infection, blood
clots in the legs or lungs, loosening or wearing out of the prosthesis, fracture, continued
pain, or stiffness. The knee-replaced joint may become loose, be dislodged, or may not
work the way it was intended. The joint may have to be replaced again in the future.
Nerves in the area of surgery may be injured, resulting in weakness or numbness. (4)
Physical therapy directly after surgery (acute) and long after surgery (post-acute), is a
very important aspect of recovery for a patient with a total knee arthroplasty. Most
surgeons prefer their patients’ get up and moving the day of surgery as long as they are
safe to do so.(2) Physical therapy addresses gait training, muscle strengthening, safety
precautions, and education. The purpose of this case report is to describe the physical
therapy plan of care for a patient in acute care who just had a total knee replacement.
Case Description
Patient
Date seen by Physical Therapist : Oct. 21, 2014. (The morning after her surgery. She was
unable to get up day of surgery due to numbness in her lower extremities nausea.)
The patient was a 70 year-old female who had a long history of knee pain, and an x-ray
showed bone on bone arthritis. She had failed conservative management and required
surgery for her next option. She lives at home with her husband, and has multiple levels
with stairs; but has many children that live near her, one daughter that she will stay with
for a few weeks until she is comfortable performing stairs independently. Patient stated
she was independent in all of her activities of daily living and could drive herself. She did
not use any assistive device previous to surgery. Her past medical history/ problems,
included: Knee pain, Anxiety, Neck pain, Osteoporosis, Depression, Suicidal ideation,
and Neuropathy. The patient was cleared by her orthopedic surgeon for weight-bearing
as tolerated on her right lower extremity.
Surgery Procedure: Right total knee arthroplasty, due to bone on bone arthritis.
Current Medications:
1. Synthroid
2. Voltaren
3. Cyanocobalamin
4. Celexa
5. Vitamin C
6. Neuro Vite
7. Fosamax
8. Neurontin
9. Oxycontin
10. Diuladid
Examination/Evaluation
The following was performed by a physical therapist the day after surgery.
Posture
Sitting Balance
Standing Balance
Range of Motion
Forward flexed
Fair sitting balance
Poor standing balance
Bilateral upper extremities and left lower extremities are within
functional limits(WFL). Right lower extremity: Knee limited to 12
degrees extension, and 93 degrees flexion
Strength (MMT)
WFL in all uninvolved extremities, Poor muscular endurance, grossly
diminished on right lower extremity.
Bed Mobility
Supine to sit- Min Assist required on Right lower extremity, head of
bed elevated
Transfers
Sit to Stand- Min Assist with Front Wheeled Walker (FWW), IV pole,
and Gait belt.
Ambulation/Stairs Distance 10 feet with FWW with min A for right lower extremity
weakness, with IV pole, gait belt, and 2 L of Oxygen
Sensation
Intact at this time, a little numb on upper thigh at time of
evaluation
Cognition
Patient fully awake and oriented
Activity Tolerance Poor endurance
Pain
3/10, in her right knee
Interventions
After examining the patient, the patient and the therapist discussed her therapy and
patient goals. The following discharge goals were set by the therapist, and her patient.
Discharge Goals: To be met in 5 days from evaluation.
1.
2.
3.
4.
Bed mobility: Stand by Assist
Transfers (sit to stand), Contact Guard Assist with FWW
Gait: patient will be able to ambulate 150 feet with FWW, CGA.
Patient and family will be independent with written home exercise program and
instructed in safety concerns.
5. Patient right knee Range of motion will be from 5 degrees extension to 90
degrees flexion.
The patient will be admitted to a rehab facility for further rehabilitation after staying
g in the acute care unit for 4 days. The patient’s physical therapy treatments were 2
times a day, from 30-45 minutes each day. The initial plan of care set by the PT
consisted of Gait Training, Transfer Training, Bed mobility, Therapeutic exercise with
TKA protocol, Stair training, and patient/family education.
GAIT TRAINING
Patient performed all gait training with a FWW and gait belt. She was weight bearing as
tolerated through her lower extremities and was allowed for standing rest breaks as
needed. Patient started by ambulating anywhere from 10-50 feet without LOB or
lightheadedness, where she would then fatigue. She required verbal cueing to take a
larger step with her left leg to create a step through pattern as well as to completely
extend her R LE to help keep it from buckling. As patient’s activity tolerance improved
her distance and quality of movement increased. On day of discharge she was able to
ambulate 250 feet with her FWW, without any rest breaks, and had 1 small buckle of
her right knee.
TRANSFER TRAINING
This included sit to stand transfers to/from different heighted chairs. Patient required
multiple verbal cues to push up from her chair with her upper extremities and to not
pull on her FWW, as well as to lean forward and push up strong from her Lower
extremities. She started requiring min A to stand up out of lower chairs. As her
strength and mobility increased patient was able to perform transfer from different
surfaces with CGA, and occasional verbal cueing to encourage safe techniques.
BED MOBILITY
Supine to/from sit- Patient was taught how to use a sheet to help lift her lower
extremities on and off the bed it there was no one around to help her, but to really try
and use the muscles in her lower extremities to increase their strength. Using the sheet
patient was able to perform bed mobility with stand by assistance. After working on her
lower extremity strength and range of motion, by discharge she could perform all bed
mobility with supervision, and no sheet to lift her right leg.
THERAPEUTIC EXERCISE
Exercises were demonstrated by a therapist prior to patient performing them, and
verbal cues were given to ensure correct form was being used. The chart below shows
what exercises the patient did each day, and how much.
DAY 2
DAY 3
DAY 4
Supine: B Ankle pumps x10encouraged to do
throughout the day!
Supine: B Ankle pumps
encouraged to do
throughout the day!
Supine: B Ankle pumps
encouraged to do
throughout the day!
Supine Heel Slides x 5
Seated Heel Slides x 10
Seated Heel Slides with
added knee stretch in
flexion x 10
Supine/Seated Quad Sets x
10
Supine/Seated Quad Sets x
10
Supine/Seated Quad Sets x
10
Glute sets x 10
Short arc quad supine: x 5
Short arc quad supine x 10
Knee Extension Stretch on
towel roll x 3, then
encouraged to leave towel
roll under leg throughout
the day as tolerated.
Knee Extension Stretch on
towel roll x 3, then
encouraged to leave towel
roll under leg throughout
the day as tolerated.
Knee Extension Stretch on
towel roll x 3, then
encouraged to leave towel
roll under leg throughout
the day as tolerated.
Hip ABD/ADD slides
seated/supine x 10
Hip ABD/ADD slides
seated/supine x 10
Seated LAQ x 5
Straight Leg Raises x 5
Hip ABD/ADD slides
seated/supine x 10
Straight Leg Raises x 10
STAIR TRAINING
Patient was talked to about stair training, and the correct form to Step up first with her
strong leg, and down first with her surgery leg. She was unable to perform stairs due to
her R knee occasionally buckling, and her fear of falling. She opted to refuse stairs and
work on them in the rehab unit once she felt her knee was stronger. She was given a
written home exercise program with instructions on stair training included.
PT/FAMILY EDUCATION
The pt and her daughter were educated on amb safety, and transfer safety. A written
HEP was given to pt, and explained to their understanding. Pt was educated to use her
FWW at all times when getting up until told not to by her doctor or PT at the rehab
center. Pt was also encouraged to not put a pillow or anything under their knee, to help
return ext to 0 degrees.
Outcomes
The following table shows the patients just before discharge. Patient was discharged
home with home health set up, as well as written instructions on care and home
exercise program. She was encouraged to use her FWW for all ambulation, transfers,
and standing activities until told to stop by her surgeon or home health physical
therapist.
Posture
Sitting Balance
Standing Balance
Range of Motion
Upright, occasional forward lean when fatigued.
Static and Dynamic sitting balance within functional limits.
Good static and dynamic standing balance with FWW for support.
Bilateral upper extremities and left lower extremities are within
functional limits(WFL). Right lower extremity extension 4 degrees,
flexion 100 degrees.
Strength (MMT)
WFL in all uninvolved extremities, Patient can perform 15
repsetitions of the following exercises: ankle pumps, ABD/ADD, SLR,
Quad Set, short arc quads, and heels slides, and 5 reps of Long arc
quads.
Bed Mobility
Supine to sit- Patient independent in bed mobility.
Transfers
Sit to Stand- stand by, to contact guard assist with FWW.
Ambulation/Stairs Distance 200 feet with FWW, gait belt, and contact guard assist.
Sensation
Intact
Cognition
Patient fully awake and oriented
Activity Tolerance Poor endurance
Pain
3-4/10, in her right knee with movement.
Discussion
The goals of physical therapy after a total knee usually fall within one of the following
categories:




Educate patient on precautions, as well as importance of extension ROM at rest.
Ability to transfer safely and independently.
Being able to ambulate safely on a level surface independently
Understanding and performing home exercise program independently. (2)
With a total knee arthroplasty the only precaution the patient must follow is to not
weight-bear on the affected leg and twist. All motions at the knee may be performed to
the patient’s comfort level.
After a total knee replacement procedure studies show that patients have decreased
strength in theirs quadriceps primarily, but also in hip abductors, and hamstrings when
compared to other adults of the same age. They also have major deficits in their range
of motion. Physical therapy can assist in increasing and restoring strength not only in
quads but focusing on hip ABD strength, as well as knee range of motion. (6)The patient
in this case report increased her strength in all of the above muscle groups, as well as
increased range of motion into flexion and extension; which in return showed a more
even gait pattern and better quality of movement while maintaining a more upright
posture.
Studies show the importance of re-gaining full extension range of motion to normalize a
patients gait pattern, as well as gaining enough flexion (105 degrees) to be fully
functional. (3)
Conclusion
Total knee replacements are becoming more prevalent as time goes on. An early acute
rehab program that includes strengthening, range of motion, and education can benefit
patients in many ways including: normal gait pattern, faster recovery, and increased
functional independence.
References
1. National Center for Health Statistics. NCHS on Inpatient Procedures. Retrieved
2010, from http://www.cdc.gov/nchs/fastats/inpatient-surgery.htm
2. Ortho Info. Total knee replacements. Retrieved December 2011 from
http://orthoinfo.aaos.org/topic.cfm?topic=a00389
3. Emory Healthcare. Total Knee Replacement Surgery. Retrieved 2014 from
http://www.emoryhealthcare.org/orthopaedics/become-patient/faq/kneereplacement.html
4. Johns Hopkins Medicine Health Library. Knee Replacement Surgery Procedure.
Retrieved 2014, from
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/orthopaedic/k
nee_replacement_surgery_procedure_92,P07673/
5. Bade MJ, Stevens-Lapsley JE (2010) Outcomes before and after total knee
arthroplasty compared to healthy adults. J Orthop Sports Phys Ther. 9, 559-567
6. Alnahdi, A., Zeni, J., Snyder-Mackler, L. (2014) Hip Abductor Strength Reliabliliy
and Association with Physical Function After Unilateral Total Knee Arthroplasty:
A Cross Sectional Study. Journal of the APTA. 90:1154-1162.