Pre-operative rehabilitation instruction.
Introduce yourself and educate patients on the need for preoperative and postoperative rehabilitation
Instruct patient on position transfer, prone to sitting, sitting to standing
Instruct the patient on postoperative knee training movements and briefly describe the training progress during hospitalization
Instruct patients to use walkers or crutches and learn to control their center of gravity
Upper extremity extensor muscle strength exercises
Postoperative days 1-3: The patient’s knee joint is usually bandaged with a drainage tube and fixed in a knee extension brace when he comes out of the operating room. The rehabilitation training mainly focuses on eliminating swelling of the affected limb, relieving discomfort of the affected limb, increasing the knee flexion angle to maintain full knee extension and restoring control of the knee muscle control, and preventing DVT of the lower limb.
Rehabilitation goals.
Control of swelling
Prevention of DVT
Pain relief
Gradually restore ROM of the affected knee (full extension and control of knee flexion within 60°)
Increase muscle control of both lower extremities and be able to contract the quadriceps well to complete SLR
Training method.
Postural elevation of the affected limb, Tri-sets, Ankle pump, 20 times per hour
Heel padding, active knee compression every hour to keep the knee fully straight for 5 minutes, sitting up and stretching the muscles and joint capsule behind the knee joint in a sitting position to improve knee extension
Wear a knee extension brace at night to maintain full knee extension and avoid postoperative flexion contracture
Release the knee extension brace on the first postoperative day with a small range of assisted knee flexion of 20°, increasing by 10-15° daily and increasing to 40-60° on the third day
For SLR centrifugal muscle exercises, start with lateral SLR in the healthy position, followed by hip flexion with knee extension in the healthy position, and then try SLR in the supine position (with knee extension brace fixed) if you can do it easily
Encourage the patient to sit up in bed and avoid prolonged lying down
After drainage tube removal, add continuous pressure cold therapy for 30-45 minutes once in the morning and once in the afternoon
Exercise the extensor muscles of the healthy leg and upper extremity to prepare for the lowering of the walker
The angle of CPM use should be increased by 10-15° daily, and the running speed should be slow during the small angle training, and the training should be done for 1 hour daily.
At this stage, if the patient reaches 60° of knee flexion and actively completes SLR (knee extension brace fixation) training, the next stage of training can be performed.
Postoperative 4-7 days: At this stage the patient’s swelling of the affected limb begins to gradually subside, control of the muscles of the lower limb is much improved, and the angle of knee flexion is increased to 90°. For patients with a high-flexion vacation body, the angle of knee flexion should be increased as much as possible without causing significant pain and swelling. Patients are encouraged to get out of bed and use a walker or crutches for tolerable weight-bearing standing and training for weight transfer.
Rehabilitation goals.
Eliminate the swelling and pain that bothers the patient
Increase active knee flexion to 90° or greater and maintain consolidation of full knee extension
Strengthen the quadriceps muscles with SLR, TKE, etc.
Increase knee flexibility and coordination
Good postural transfer
Pain tolerant weight bearing
Balance and gait training
Training methods.
CPM/Wall slide
Active knee flexion and extension (knee slide on the bed in supine position or knee slide back and forth on the floor with the foot in a chair)
Consolidate knee extension for 5 minutes every hour (high pressure knee pad under the foot, or knee extension and stretch in sitting position)
Relaxed back and forth leg swing at the bedside to increase flexibility of the affected knee
SLR in all directions, if there is no lag in knee extension, SLR can be trained off the knee extension brace
TKE, hitching, N cord muscle strength training
NMES to promote quadriceps control
Supported stance with knee extension brace immobilization
Postural transfer training with assistance
Partial weight-bearing, left-right and right-back shifts
Standing leg flexion exercises
Stepping in place
CRYO/CUFF
At this stage, if the patient reaches 0-90° knee flexion and extension and has good quadriceps strength, he/she can complete the transfer independently and start the next stage of training.
Post-operative 8-14 days: In the second post-operative week the patient’s control of knee flexion is improved, at this time the main focus of training will be on continuing to increase ROM and training of lower limb muscle strength and walking ability
Rehabilitation goals.
Pain control
Consolidation of knee extension
Increased knee flexion to 100-120°
Good weight bearing and closed chain muscle control of the lower extremity
Improved gait, independent walker or crutch supported walking
Self-supported step-up and step-down exercises
Training methods.
Active knee flexion in supine, standing and sitting positions
Consolidation of full knee extension
SLR, supine and weighted TKE
Standing knee flexion and heel lift exercises
Supported standing micro-squats
Sit-stand-sit exercises
Lower limb centrifugal weight training
Strengthening independent position transfer training
Walker-supported walking exercises
Balance training advancement
Self-supporting step-up and step-down exercises
Cold compress after training
2 weeks to one month after surgery: At this stage, patients mainly exercise on their own to maintain and consolidate ROM, muscle strength and walking ability, and gradually return to normal life.
Rehabilitation goals.
Consolidation ROM and muscle strength training
Good coordination of lower limb movement
Good ability to live at home by oneself
Stable walking ability to prevent falls
Increase physical fitness
Training methods
Consolidation of muscle strength and ROM training
Partial to full weight-bearing
Balance and anti-fall exercises
Walking on flat ground
Return to normal daily life at home
Cold compresses after ROM and ambulation training
At this stage, if the patient has achieved good ROM and muscle strength, and the ability to transfer to an active and independent position, he/she will proceed to the next stage of training
One month to three months after surgery.
Rehabilitation goals.
Painless full range ROM
Improved motor ability
Training methods.
Micro-squats
Balance board training
Obstacle walking training
Small area walking
Walking in the pool or power bicycle training
3 months to 6 months after surgery: At this stage, patients basically integrate into normal life, and are encouraged to participate in small-load sports exercises such as swimming, hiking, table tennis, bowling, bicycling, etc. under the condition of physical operation, but for sports with high intensity, frequent body collisions, and sports that require repeated flexion and rotation of the lower limbs such as basketball, soccer, tennis badminton, etc., it is better to avoid participation to increase the protection of the prosthesis and To prevent falls.
Post-operative rehabilitation mainly focuses on muscle strength training, mobility training, postural transfer training, gait training and so on. For each patient, an individualized rehabilitation program should be developed, and the program should be fine-tuned according to the patient’s daily recovery status. Avoid emphasizing a certain training goal and increasing the intensity of training beyond the patient’s tolerable level, causing the patient to fear training and avoid training. Therefore, the training progress should be gradual, while timely communication with the patient should be made so that the patient understands that pain is inevitable during training and works with the physician to provide analgesic treatment to reduce the patient’s discomfort and pain during training.
For patients with bilateral total knee replacements, postoperative pain and muscle strength recovery will be slower than for unilateral replacements, therefore, more analgesic treatment and ROM training are needed to instruct patients to learn to train actively as soon as possible to consolidate the training effect, and to restore more knee flexion angle to facilitate future sitting and standing transfer and life. Patients with simultaneous bilateral replacements should also be weighted a little later.
Some patients may experience joint stiffness after knee arthroplasty, and ROM training may be difficult and ineffective. Keep the surgeon informed of the patient’s training progress, especially if there is no significant progress or regression by the second postoperative week.
Patients should be discharged from the hospital 14 days after surgery. ROM, muscle strength, postural transfer and ADL should be assessed before discharge, and a discharge training plan should be formulated based on the assessment results, and patients should be instructed to continue training at home or referred to a rehabilitation center.
For patients with slower muscle strength recovery or difficult ROM recovery, they will return to the outpatient clinic 3 times a week to continue training under the guidance of the therapist. For older patients with more severe osteoporosis, full weight bearing is preferred later.