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  • Study: Progressive Strengthening Program Shows Promise Over 'Standard of Care' Rehab for Patients Post-TKA

    In brief:

    • Reseachers studied 2 groups of adults 50 and over who underwent total knee arthroplasty (TKA): 1 group that engaged in "standard of care" rehabilitation, and 1 group that participated in a clinic's progressive strengthening program. The groups were compared with each other and with a group of adults 50 and older who had no joint pathology.
    • Function was assessed through knee flexion measures, knee extension measures, quadriceps strength measures, the timed up-and-go test (TUG), stair-climbing time (SCT), the 6-minute walk test (6MW), and patient self-reports.
    • Overall, neither the strengthening group nor the standard-of-care group achieved function equivalent to the control group, but the strengthening group more often achieved scores at or better than lower-boundary scores of the control group.
    • Authors believe a progressive strengthening approach can bring TKA patients closer to "normal clinical and functional scores" than can standard-of-care approaches focused on range of motion and exercises without weights.

    Adults 50 and older who undergo TKA may never fully achieve the same function as older adults without knee pain, but a progressive strengthening exercise program may bring them closer to those levels than would the variable approaches considered "standard-of-care," according to authors of a recent study.

    The study compared self-reported function and test performance for 3 groups: 88 adults aged 50 and older without knee or joint pain (and no TKA); 40 adults aged 50 and older who underwent TKA and participated in "standard-of-care" rehabilitation; and 165 adults aged 50 and over who underwent TKA and participated in what authors describe as an outpatient clinic program that "included progressive strengthening exercises that targeted muscle groups in the lower extremity." Results were published in Physiotherapy Theory and Practice (abstract only available for free).

    The strengthening program was conducted at a University of Delaware physical therapy clinic beginning 3 weeks after TKA, and consisted of at least 12 outpatient visits 2–3 times a week. The visits themselves focused on strengthening exercises that were progressively adjusted to maintain maximal effort for 3 sets of 10 repetitions for all exercises. The "standard of care" group participated in outpatient rehabilitation elsewhere for an average of 23 sessions that mostly focused on range of motion (ROM), stationary cycling, and "various straight-leg raising exercises without weights," according to the study's authors.

    Both TKA groups were evaluated 12 months after surgery by way of 7 measures: the Knee Outcome Survey-Activities of Daily Living (KOS-ADL) self-assessment, measures of active knee flexion, measures of active knee extension, measures of quadriceps strength, TUG, SCT, and 6MW. Researchers then compared these groups with each other, as well as with results from the 88 older adults who had no history of knee pain (control group). Authors of the study were especially interested in finding out how many participants in each TKA group achieved scores at the lowest bounds of the control group. Here's what they found:

    • The control group consistently reported higher KOS-ADL scores, greater active knee ROM, greater strength, and better performance on TUG, SCT, and 6MW than either TKA group—a result that authors say is consistent with past research showing that function post-TKA hardly ever reaches the levels of age-matched individuals without joint pathology.
    • Compared with the standard-of-care group, a higher percentage of strengthening group participants achieved scores at or above the lower-boundary control group cutoff in knee extension ROM (30% in the strengthening group versus 15% in the standard-of-care group), quadriceps strength (18% vs 5%), and SCT (34% vs 18%). No significant differences were found in KOS-ADL scores, knee flexion ROM, TUG, and 6MW.
    • Compared with the standard-of-care group, participants in the strengthening group were twice as likely to achieve performance above the lower-boundary cutoff for knee extension angle and SCT, and 4 times as likely as the standard-of-care participants to outperform the cutoff for quadriceps strength.
    • Overall, 67% of the strengthening group achieved an above-cutoff score in at least 1 of the 7 variables measured, compared with 47.5% of participants in the standard-of-care group.

    "A greater proportion of patients who participated in the progressive strengthening protocol achieved what could be considered normal clinical and functional scores," authors write. "This suggests that although clinicians cannot expect TKA to restore normative function for all individuals, participating in a progressive strengthening protocol may improve the likelihood of achieving normal age-matched outcomes for a subset of patients."

    Aside from their lack of focus on strengthening, "standard of care" approaches also may be less effective because often they are anything but "standard," according to authors.

    "The lack of consensus between therapists and surgeons on the optimal timing and amount of rehabilitation, and substantial variability in timing, amount, and exercise content of rehabilitation services, may potentially have important negative effects on postsurgical outcomes," they write. "Failure to restore function by 12 months after TKA may be deleterious, as outcome measures plateau around 12 months following TKA, and no meaningful gains have been observed with longer-term follow ups."

    Authors acknowledge several limitations of their study, including a smaller number of participants in the standard-of-care group, and the fact that both TKA groups were heavier than the control group.

    APTA members Federico Pozzi, PT, MA, PhD; Daniel K. White, PT, ScD, MSc; Lynn Snyder-Mackler, PT, ScD FAPTA; and Joseph A. Zeni, PT, PhD, were among the coauthors of the study.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.


    • This article leaves a lot to be desired. Practicing PT for many years, I have NEVER SEEN a standard of care described as rom, bicycle and SLR'S. This is a poor article and a disgrace to our profession/ is this what new grads are observing in the clinic?

      Posted by Michelle Guevin on 6/21/2018 10:37 PM

    • I have to agree with Michelle Guevin's comments. I have been practicing for 32 years and even in the 1980s we treatment based on a thoughtful algorithm. Initially control swelling (back then, there was a lot of swelling) with compression, elevation and a compression pump that circulated cold water. We let the swelling go down for 3 days and then it was a mandatory 90 degree bend in the clinic. That is much easier today as much less trauma and swelling and 90 degrees is achieved on the day of surgery. Once swelling is controlled and range of motion is easily maintained above 90 degrees then progress strengthening program, primarily in an closed chain--walking, sit to stand or squats, mini lunges. At the same time working on balance. If the patient has good home health PT post op, much of this is taken care of prior to the patient even getting to OPPT. I just progress their home exercise program and balance program usually every 1-3 weeks over several months. Typically patients have excellent strength, a pretty normal gait, can navigate stairs and have 120 plus degrees of PROM. I don't know where the "standard care" came from--it is not standard nor does it meet even the most minimal standards of what is taught in PT school as well as continuing ed. Straight leg raises and bike, that's it? Really. If I were the patient, I would have to head somewhere else.

      Posted by Herbert Silver -> >JX^D on 6/26/2018 6:12 PM

    • who would pay for 23 sessions of ROM, cycling and SLR's? Certainly not what is being taught in our PTA program

      Posted by Mike Spitz on 6/27/2018 1:31 PM

    • I agree with previous posters. Research is needed but research that targets real clinical issues/problems. Sometimes we seem to be generating "research" just for the sake of generating tesearch. Academia anyone???

      Posted by Mike Williams on 7/13/2018 3:30 PM

    • I absolutely agree with Michelle Guevin. This so-called standard of care is not any standard of care that I have ever personally practiced or witnessed effective practitioners practice. Frankly, this article is off little use other than to add to the growing body of evidence that much present day research is rather pedestrian and seems to be of little or no real world value. .

      Posted by Brian Miller -> =KX[> on 7/13/2018 10:11 PM

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