How Can a Physical Therapist Help Before & After

Surgery?
Before Your Surgery ("Pre-op Conditioning")
The better physical shape you are in before TKR surgery, the better your results will be
(especially in the short term). Before surgery, your physical therapist will teach you exercises
and show you how you will walk with assistance after your operation. Your therapist also
will discuss precautions and home adaptations, such as removing loose rugs or strategically
placing a chair so that you can sit instead of squatting to get something out of a low cabinet.
It's always easier to make these modifications before you have TKR surgery.

If you smoke, quit! That may help improve your healing after surgery. If you are overweight,
focus on weight loss prior to surgery. Losing excess body weight may help you recover more
quickly, and help improve your function and overall results following surgery.

Immediately Following Your Surgery

With a TKR, you likely will stay in the hospital 2 or 3 days following your surgery. If you
have other medical conditions, such as diabetes or heart disease, you might need to stay an
additional few days. If you are like most patients, you will be told to put as much weight as
comfortable, when standing, on the leg that had surgery. While you are in the hospital, a
physical therapist will:

Show you how to practice walking with a walker or crutches

Teach you how to safely get in and out of bed or a chair

 Help you continue to do the flexibility and strengthening exercises that you learned
before your surgery

During this period, it's especially important to control the swelling in your knee and to help
your incision heal. Your physical therapist may perform electrical stimulation, where
electrodes are placed on the skin to stimulate the nerves around the knee to help reduce pain
and swelling and promote healing.

Your therapist also may apply cold to the knee to help decrease swelling and may
recommend that you wear support stockings.

As You Begin to Recover

Proper rehabilitation after a TKR is essential to your recovery. Your physical therapist will
help you regain much of your knee range of motion as soon as possible. At this point, you
might be walking with a cane or with one crutch.

Your physical therapist can speed up (or "hasten") your return to activity and help make your
new knee better than the old one! Your therapist will tailor range-of-motion exercises,
progressive muscle-strengthening exercises, body awareness and balance training, and
activity-specific training to your specific needs.

Occasional swelling of the knee joint and lower leg can occur for up to 3 months after
surgery. To relieve swelling, you can wear support stockings, apply a cold pack, and elevate
your lower leg on a pillow when sitting or lying down.

Range-of-motion exercises. Swelling and pain can make you move your knee less. Your
physical therapist can teach you safe and effective exercises to restore the range of motion to
your knee so that you can perform your daily activities.

Strengthening exercises. Weakness of the muscles of the thigh and lower leg could make
you need to use a cane when walking. Your physical therapist can determine which
strengthening exercises are right for you, with the goal of no longer needing to use a cane to
walk.

Body awareness and balance training. Specialized training exercises help your muscles
"learn" to respond to changes in your world, such as uneven sidewalks or rocky ground.
When you are able to put your full weight on your knee without pain, your physical therapist
may add agility exercises (exercises that have you practice making quick stops and starts,
turns, and changes in direction) and activities using a balance board that challenge your
balance and knee control. Your program will be based on the physical therapists examination
of your knee, on your goals, and on your activity level and general health.

Functional training. When you can walk freely without pain, your physical therapist may
begin to add activities that you were doing before your knee pain started to limit you. These
might include community-based actions such as crossing a busy street or getting on and off
an escalator. Your program will be based on the physical therapist's examination of your
knee, on your goals, and on your activity level and general health.

The timeline for returning to leisure or sports activities varies from person to person; your
therapist will be able to estimate yours based on your specific condition.
Activity-specific training. Depending on the requirements of your job or the type of sports
you play, you might need additional rehabilitation that is tailored to your job activities (such
as climbing a ladder) or sport activities (such as swinging a golf club) and the demands that
they place on your knee. A physical therapist can develop a rehabilitation program that takes
all of these demands into account.
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Can this Injury or Condition be Prevented?

If you have knee pain, you may be able to delay the need for surgery by working with a
physical therapist to improve the strength and flexibility of the muscles that support and
move the knee. This training could even help you avoid surgery altogether. Participating in an
exercise program designed by a physical therapist can be one of your best protections against
knee injury. And staying physically active in moderately intense physical activities and
controlling your weight through proper diet might help reduce the risk of osteoarthritis of the
knee getting worse.
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Real Life Experiences

Carmella is a 67-year-old grandmother of 3 who has had osteoarthritis in her right knee for
many years. She used to take care of her grandchildren after school each day before her
daughter got home from work. Then Carmella's knee became so painful that she could no
longer walk up and down stairs or stand for long periods of time. She also had a lot of
difficulty getting up from a chair. She had to tell her daughter that she couldn't take care of
her grandchildren anymore. Carmella decided it was time to receive a total knee replacement.
Her surgery was successful and had no complications.

The first day after her surgery:

A physical therapist came to Carmela's room in the hospital and began teaching her deep-
breathing exercises to help her improve her breathing after surgery. The therapist also
showed her how to bend and straighten her knee, and how to to tense and then relax and
release her knee, calf, and hip muscles to strengthen them. The therapist then helped
Carmella practice sitting and standing at the edge of her hospital bed, and to begin bending
and straightening her new knee joint.

The second day after surgery:

Carmella started walking with crutches with the therapists assistance, putting a little weight
on her right leg. The therapist also instructed her in some gentle leg-strengthening exercises.

The third day after surgery:

Since Carmella was able to walk without the therapist's aid in the hospital hallways and up
and down a few stairs, she was allowed to return home with her crutches. Her therapist
designed an at-home exercise program just for her, and taught it to her.

Once Carmella returned home, a home care physical therapist regularly visited her at her
house to continue her rehabilitation.

The therapist prescribed more challenging exercises for Carmella that added weights for
strengthening. Carmella also began to practice walking with a cane instead of her crutches.

About 12 weeks after her surgery:

Carmella felt hardly any pain in her knee. She could walk without using a cane, but she still
needed to use a handrail when going up or down the stairs. At times, her knee felt "shaky."
She still could not take care of her grandchildren because of these remaining challenges.

Carmela's therapist instructed her in more aggressive strengthening and movement exercises
for her hips, knees, and ankles. The therapist also worked with her on improving her stair
climbing, her balance, and her agility. After 6 weeks (12 physical therapy sessions), Carmella
felt confident walking up and down the stairs, getting in and out of her car and driving, and
performing other daily activities. She felt that her new knee was much more stable.

Later that month, Carmella was able to take care of her grandchildren again. She also joined a
health club that offered exercise programs for older adults so she could maintain the benefits
she had gained from her physical therapy.

This story was based on a real-life case. Your case may be different. Your physical therapist
will tailor a treatment program to your specific case.
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What Kind of Physical Therapist Do I Need?

Although all physical therapists are prepared through education and experience to treat
people who have a TKR, you may want to consider:

A physical therapist who is experienced in treating people with orthopedic, or

musculoskeletal, problems

A physical therapist who is a board-certified clinical specialist or who has completed

a residency or fellowship in orthopedic physical therapy, giving the therapist
advanced knowledge, experience, and skills that may apply to your condition

You can find physical therapists who have these and other credentials by using Find a PT, the
online tool built by the American Physical Therapy Association to help you search for
physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist:

Get recommendations from family and friends or from other health care providers.
 When you contact a physical therapy clinic for an appointment, ask about the physical
therapist's experience in helping people with TKR.

During your first visit with the physical therapist, be prepared to describe your symptoms in
as much detail as possible, and say what makes your symptoms worse.
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Further Reading
The American Physical Therapy Association (APTA) believes that consumers should have
access to information that could help them make health care decisions and also prepare them for
their visit with their health care provider.

The following articles provide some of the best scientific evidence about physical therapist
treatment of TKR. The articles report recent research and give an overview of the standards of
practice for treatment both in the United States and internationally. The article titles are linked
either to a PubMed abstract (summary) of the article or to free access of the entire article, so that
you can read it or print out a copy to bring with you when you see your health care provider.

Piva SR, Gil AB, Almeida GJ, et al. A balance exercise program appears to improve function for
patients with total knee arthroplasty: a randomized clinical trial. Phys Ther. 2010;90:880
894. Free Article.

Piva SR, Teixeira PE, Almeida GJ, et al. Contribution of hip abductor strength to physical
function in patients with total knee arthroplasty. Phys Ther. 2011;91:225233. Free Article.

Moffet H, Collet JP, Shapiro SH, et al. Effectiveness of intensive rehabilitation on functional
ability and quality of life after first total knee arthroplasty: a single-blind randomized controlled
trial. Arch Phys Med Rehabil. 2004;85:546556. Free Article.

Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after
knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised
controlled trials. BMJ. 2007;335:812. Free Article.

Bade MJ, Kohrt WM, Stevens-Lapsley JE. Outcomes before and after total knee arthroplasty
compared to healthy adults. J Ortho Sports Phys Ther. 2010;40:559567. Article Summary on
PubMed.

Walls RJ, McHugh G, OGorman DJ, et al. Effects of preoperative neuromuscular electrical
stimulation on quadriceps strength and functional recovery in total knee arthroplasty: a pilot
study. BMC Musculoskelet Disord. 2010;11:119. Free Article.

Topp R, Swank AM, Quesada PM, et al. The effect of prehabilitation exercise on strength and
functioning after total knee arthroplasty. PM R. 2009;1:729735. Article Summary on PubMed.

Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for
osteoarthritis of the knee [erratum in: N Engl J Med. 2009;361:2004]. N Engl J Med.
2008;359:10971107. Free Article.

Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness of manual physical therapy and
exercise in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med.
2000;132:17381. Free Article.
Dowsey MM, Liew D, Choong PF. The economic burden of obesity in primary total knee
arthroplasty. Arthritis Care Res(Hoboken). 2011 July 26 [Epub ahead of print]. Article Summary
on PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology
Information (NCBI). PubMed contains millions of citations to biomedical literature, including
citations in the National Library of Medicines MEDLINE database.

Authored by Anne Reicherter PT, DPT, PhD, OCS. Reviewed by the MoveForwardPT.com
editorial board.