Background
Methods
Search strategy
Database | Search Terms | ||
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PubMed CINAHL Embase COCHRANE PEDro | “Arthroplasty, Replacement, Knee” (MESH) OR Knee Replacement OR TKR | AND | “Physical therapy Modalities” (MESH) OR Physical therapy OR “Rehabilitation” (MESH) OR Rehabilitation |
Eligibility criteria
Inclusion criteria
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Articles available in full text
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Articles in English
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A key term was required in the study Title or Abstract
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Study design was a randomized controlled or quasi-experimental trial
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A Therapist-led exercise intervention. CPM therapy was not included in this study as the experimental intervention, however, could be part of a patient’s standard care.
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Study setting: exercise intervention commenced in the acute hospital period within 48 h of TKR surgery and prior to discharge from the inpatient setting
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Participants were post-operative primary unilateral total knee replacement patients
Study selection
Data extraction
Methodological quality
Statistical analysis
Results
Search, screening, and selection results
Description of included studies
General characteristics of participants
Author, Year, Study Location | Title | No. of Participants | Gender (M/F) | Mean Age & Range if reported (Years) | Inclusion Criteria | Exclusion Criteria | |||
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Dujin, P., Jeonghee, K., & Hyunok, L. (2012). Busan, Korea | Effectiveness of Modified Quadriceps Femoris Muscle Setting Exercise for the Elderly in Early Rehabilitation after Total Knee Arthroplasty | Cont | Exp | Cont | Exp | Cont | Exp | TKR patients, Walk alone with/without cane, FFD < 10 deg., Able to communicate, No disease in parts of body except knee joint | Not provided |
22 | 22 | M 0 F 22 | M 0 F 22 | 70.3 | 69.1 | ||||
Hewitt, B., & Shakespeare, D. (2001). Warwickshire, United Kingdom | Flexion vs. extension: a comparison of post-operative total knee arthroplasty mobilization regimes | Cont | Exp | Cont | Exp | Cont | Exp | Unilateral TKR patients | No exclusion criteria |
74 | 86 | M 33 F 41 | M 41 F 45 | 71.7 | 73.4 | ||||
Kim, T., Park, K., Yoon, S., Kim, S., Chang, C., & Seong, S. (2009). Seoul, Korea | Clinical value of regular passive ROM exercise by a physical therapist after total knee arthroplasty | Cont | Exp | Cont | Exp | Cont | Exp | Primary diagnosis of OA, undergoing staged bilateral TKRs, no prior surgery to the knees, normally functioning hip joints, | Unilateral TKR, Wound Complication |
50 | *50 | M 0 F 50 | M 0 F 50 | 67.9 (53–83) | 67.9 (53–83) | ||||
Pongkunakorn, A., & Sawatphap, D. (2014). Lampang, Thailand | Use of drop and dangle rehabilitation protocol to increase knee flexion following total knee arthroplasty: a comparison with continuous passive motion machine | Cont | Exp | Cont | Exp | Cont | Exp | Unilateral TKR patients | FFD > 30 deg., Uncooperative patients, Intraoperative complication preventing early knee motion |
33 | 36 | M 4 F 29 | M 2 F 34 | 68.5 (54–82) | 67.0 (57–81) | ||||
Totals | 179 | 194 | M 37 F 142 | M 43 F 151 | 69.6 | 69.3 |
Author | Eligible for Inclusion | Excluded | Number Allocated | Excluded post allocation | Lost to follow up | Included in final analysis | ||
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Cont | Exp | Cont | Exp | |||||
Dujin, P., Jeonghee, K., & Hyunok, L. | 44 | 0 | 22 | 22 | 0 | 0 | 22 | 22 |
Hewitt, B., & Shakespeare, D. | 160 | 0 | 74 | 86 | 0 | 0 | 74 | 86 |
Kim, T., Park, K., Yoon, S., Kim, S., Chang, C., & Seong, S. | 106 | 6 | 50 | 50 | 0 | 0 | 50 | 50 |
Pongkunakorn, A., & Sawatphap, D | 86 | 0 | 41 | 45 | 10 | 7 | 33 | 36 |
Totals | 396 | 6 | 187 | 203 | 10 | 7 | 179 | 194 |
Exercise therapy interventions
Author | Control | Experimental | Delivery of Intervention | ||
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Timing | Frequency | Duration | |||
Dujin, P., Jeonghee, K., & Hyunok, L. | Conventional Quadriceps Setting (CQS) Protocol Supine position, operated limb in knee extension & ankle dorsiflexion, with a 10s isometric quadriceps contraction CPM daily for 1 h until week 2 post-op. Week’s 2–4 add resistance training for knee flexor and extensor muscles and cycling 1 h/day, 5 times a week. | Modified Quadriceps Setting (MQS) Protocol Seated position (90-degree hip & knee angle) operated limb performed 10s isometric quadriceps contraction with 2 kg sandbag on the other ankle. CPM daily for 1 h until week 2 post-op. Week’s 2–4 add resistance training for knee flexor and extensor muscles and cycling 1 h/day, 5 times a week. | Cont Daily Exp Daily | Cont 10 Repetitions Exp 10 Repetitions | Cont 3 sets with 1 min breaks Exp 3 sets with 1 min breaks |
Hewitt, B., & Shakespeare, D. | Extension Splint Protocol Immediately post-op, knee placed out straight in a knee immobiliser splint remaining on overnight. Multi-exercise regime with physio commenced day 1 including knee flexion exercises. Knee extension splint only night of day 1, then no longer applied. Exercises continued daily until discharge. | Flexion Splint Protocol Immediately post-op, knee placed on a 90-degree splint remaining on overnight. Physio day 1, 2hrly knee flexed 90d and placed on the 90d splint for 10 mins, the knee was then allowed to straighten out and hang in passive extension for 10 min with ankle supported on a foam block. Multi-ex regime also added to physio day 1. From day 2 the flexion block regime was ceased once the knee could be actively flexed to 90 degrees, the same standard was set for the night flexion splint. | Cont Daily Exp Daily | Cont Once Exp 2-hrly until active KROM = 90d after day 2 | Cont Overnight day 0–1 Exp 2-hourly and overnight |
Kim, T., Park, K., Yoon, S., Kim, S., Chang, C., & Seong, S. | No-PROME Protocol Day 0 = quad’s strength ex Day 1 = 50 mins CPM 0–30 degrees + gait training, CPM ROM gradually increased over next two weeks Day 2 = Same as 1 & 2 and add Drop/Dangle + active knee ROM ex’s Day 3–14 = Physio once daily in the rehab centre | PROME Protocol 40 min of physiotherapy: First 20 = quad’s strength + gait training Second 20 = PROME ex (pt placed in supine, 5 mins thigh/calf massage, then PROME routine consisted of holding leg in ext. for first 5 s, then max tolerated flexion for 5 s, one cycle of this took ~20s and 40–50 cycles were performed. | Cont Daily Exp Daily | Cont Once Exp Once | Cont 50 mins Exp 40 mins |
Pongkunakorn, A., & Sawatphap, D | CPM Protocol Bandaged in extension post-op and removed day 1 and placed on CPM 0–60 degrees. ROM was increased by 15 degrees or more each day unless not tolerated, progressively increased to115d. Both groups received the same other ROM ex’s and quad strengthening program. | Drop and Dangle Protocol Placed in 70-degree flexion splint post-op then removed day 1. D&D day 1 in a seated position, maximal passive overpressure with the other foot then held for 10s. Then actively assisted into extension by other foot. Both groups received the same other ROM ex’s and quad strengthening program. | Cont Daily Exp Daily | Cont 3 times Exp 3 times | Cont 1 h Exp 1 h |
Outcomes
Author | Outcome Measure(s) | How Outcome was measured | Validity/Reliability | Frequency of Outcome | Adverse Events |
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Dujin, P., Jeonghee, K., & Hyunok, L. | 1) Muscle strength: Quadriceps, Hamstrings, Gluteus Maximus [31] 2) 6 Minute Walk Test [32] | 1) Handheld dynamometer 2) Distance (m) | All outcomes are valid & reliable | All outcomes were measured pre-operatively and at 2 weeks and 4 weeks post-surgery. | Nil reported |
Hewitt, B., & Shakespeare, D. | 1) Knee Society knee & function scores [33] 2) FFD [34] 3) Max Flex [34] 4) ROM [34] 5) Analgesic Requirements 6) Blood Loss | 1) Survey 2) Goniometer 3) Goniometer 4) Goniometer 5) Medical Chart 6) Medical Chart | Outcomes 1–4 are valid and reliable; outcomes 5 & 6 have not been reported by the authors Only Outcome’s 2, 3 & 4 have values reported by the authors, there are no values reported for outcomes 1,5 & 6. | Outcomes 1–4 were measured pre-operatively (1 day prior to OT) and 6 weeks post-surgery; Outcomes 5–6 were measured during admission. | Nil reported |
Kim, T., Park, K., Yoon, S., Kim, S., Chang, C., & Seong, S. | 1) Knee Society knee & function scores [33] 2) WOMAC scores 3) Flexion contracture [34] 4) Max Flex [34] 5) Patient reported preference of protocol | 1) Survey 2) Survey 3) Goniometer 4) Goniometer 5) Survey | Outcomes 1–4 are valid & reliable; Outcome 5 has not been tested for validity or reliability | Outcomes 1 & 2 were measured pre-operatively and 6 months post-surgery; Outcomes 3 & 4 were measured pre-operatively & at 7 days, 14 days, 6 weeks, 3 months and 6 months; Outcome 5 was assessed at day of discharge. | Nil reported |
Pongkunakorn, A., & Sawatphap, D | 1) OT time 2) Blood Loss 3) LOS 4) Knee Society knee & function scores [33] 5) Passive Flexion ROM [34] | 1) Medical Chart 2) Medical Chart 3) Medical Chart 4) Survey 5) Goniometer | All outcomes are valid & reliable | Outcomes 1–4 were measured during admission; Outcome 5 was measured during admission (once daily for 7 days until d/c), and at 6 weeks and 1-year post-surgery. | Nil reported |
Patient reported outcome measures
Knee flexion and functional mobility
Meta-analysis results
Methodological quality
Author | Study Design | Reporting | External Validity | ||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | |||
Dujin, P., Jeonghee, K., & Hyunok, L. | Randomised Controlled Trial | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | |
Hewitt, B., & Shakespeare, D. | Prospective non-randomised controlled trial (Quasi-Experimental) | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | |
Kim, T., Park, K., Yoon, S., Kim, S., Chang, C., & Seong, S. | Randomised Controlled Crossover Trial | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | |
Pongkunakorn, A., & Sawatphap, D | Prospective non-randomised controlled trial (Quasi-Experimental) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | |
Author | Internal Validity Bias | Internal Validity Confounding | Power | Total Score | |||||||||||
14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | ||
Dujin, P., Jeonghee, K., & Hyunok, L. | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 1 | 20 |
Hewitt, B., & Shakespeare, D. | 0 | 0 | 1 | 1 | 1 | 1 | 0 | 1 | 1 | 0 | 0 | 1 | 1 | 0 | 18 |
Kim, T., Park, K., Yoon, S., Kim, S., Chang, C., & Seong, S. | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 22 |
Pongkunakorn, A., & Sawatphap, D | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 20 |