Rehabilitation After Total Knee Replacement: An Evidence-Based Approach.

Student thesis: Doctoral Thesis


Total knee replacement (TKR) remains the treatment of choice for severe end-stage knee osteoarthritis, which is unresponsive to non-operative management, leading to a higher quality of life, less pain and better mobility. The predicted rise in rates of knee osteoarthritis due to obesity and an aging population will be matched with an increased number of TKR procedures being performed. Despite TKR being cost-effective at an individual level, the societal financial burden from a surge in TKR rates is of significant concern. Healthcare stakeholders are increasingly focused on resource efficiency, and with acute-care and rehabilitation expenditure comprising a sizeable portion of the costs associated with TKR, there is attention on the value of rehabilitative care.

Despite physiotherapy being considered as a routine part of TKR rehabilitation, considerable variation in practice exists. This thesis explored the literature for evidence concerning rehabilitation protocols and discharge destination associated with TKR surgery (Chapters 2, 4 and 5). Clinical research was then conducted in the areas identified to be lacking, including both physiotherapy
intervention and patient factors predictive of discharge destination (Chapters 3 and 6).

The findings of this thesis highlight the paucity of evidence currently available to guide physiotherapists on “best-practice” rehabilitation after TKR surgery. Existing literature primarily focuses on passive modalities such as continuous passive motion (CPM), with a shortage of evidence to be found concerning active exercise interventions which form the basis for most TKR physiotherapy protocols. As part of this thesis, a randomised controlled trial (RCT) was conducted on differing physiotherapy exercise protocols after TKR surgery, identifying that a simple three-exercise bike pedalling protocol was superior to a standard multi-exercise physiotherapy regime.

Despite growing evidence that early discharge after TKR with a home-based exercise protocol provides better outcomes without increasing complications, a significant proportion of patients still discharge to an inpatient rehabilitation facility. This thesis identified that although demographic factors such as age and social support have been shown to be predictive of inpatient rehabilitation
discharge, the most predictive factor is a patient’s belief about the superiority of inpatient rehabilitation and the perceived challenges of completing their rehabilitation at home.

Predicting those patients that are most likely to discharge to inpatient rehabilitation after primary TKR allows for early, targeted interventions to optimise resource allocation and increase likelihood of home discharge. The identification of patients that have concerns about returning directly to home after TKR provides an opportunity for discussion and reassurance regarding the assessment of readiness for home discharge, and the positive evidence for the efficacy of home-based exercise protocols.
Date of Award3 Feb 2021
Original languageEnglish
SupervisorWayne Hing (Supervisor), Ben Schram (Supervisor) & Christopher Vertullo (Supervisor)

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