Early Regain of Function and Proprioceptive Improvement Following Knee Arthroplasty

Document Type : RESEARCH PAPER

Authors

1 Brigham and Women’s Hospital, Boston, MA, USA

2 Great Plains Orthopedics, North Platte, NE, USA

Abstract

Background: Techniques that allow early muscle activation, such as closed kinetic chain (CKC) and open kinetic
chain (OKC) exercises, may play a beneficial role in the early rehabilitation of the reconstructed knee. However,
current rehabilitation regimens have not been shown to reverse post-operative quadriceps activation failure
and weakness. To investigate whether patients who use a continuous active motion (CAM) device that follows
closed kinetic chain principles have better early post-operative functional improvements than patients who use a
continuous passive motion (CPM) device that follows the principles of open kinetic chain principles. A prospective
randomized controlled trial with non-blinded study staff. A tertiary care clinic at a teaching hospital. A total of 110
patients signed the consent form and 83 patients participated in the study.
Methods: Patients were randomly assigned to use either the CPM device for 4 hours daily for 3 weeks (control
group), or a CAM device for 3 sessions of 20 minutes for 3 weeks (intervention group), starting 24 hours after
knee replacement surgery.The primary outcome measure was to identify the superiority, inferiority, or equivalence
of one device at week 4 after knee arthroplasty using various functional outcome measures such as kinesthesia,
quadriceps strength, coordination, general orthopaedic outcome measures and narcotic consumption.
Results: At 4 weeks, all outcome measurements were comparable between the two groups, with the exception
of sit-to-stand test: in the treatment group the time was significantly shorter compared to the control group
(P=0.016). Balance was significantly better in both control (P=0.001) and treatment group (P=0.032) compared
to prior surgery.
Conclusion: Most clinical centers would like to expedite functional recovery of knee arthroplasty patients without
increasing the risk of falls. We observed balance and kinesthesia improvements after surgery using either
device which may be important to benefit fast recovery programs. Further research is warranted to see whether
additional active closed kinetic chain exercised following knee replacement surgery could improve specific
functional outcomes such the observed sit-to-stand test.

Keywords

Main Subjects


1. Fitz W, Scott RD. Unicompartmental knee arthroplasty.
Insall Scott Surg Knee. 2012; 5(98):988-95.
2. Overstall PW, Exton-smith AN, Imms FJ, Johnson AL.
Falls in the elderly related to postural imbalance. Br
Med J. 1977; 1(6056):261-4.
3. Mizner RL, Petterson SC, Stevens JE, Axe MJ, Snydermackler
L. Preoperative quadriceps strength
predicts functional ability one year after total knee
arthroplasty. J Rheumatol. 2005; 32(8):1533-9.
4. Paul JE, Arya A, Hurlburt L, Cheng J, Thabane L, Tidy A, et
al. Femoral nerve block improves analgesia outcomes
after total knee arthroplasty: a meta-analysis of
randomized controlled trials. Anesthesiology. 2010;
113(5):1144-62.
5. Mizner RL, Petterson SC, Stevens JE, Vandenborne K,
Snyder-mackler L. Early quadriceps strength loss after
total knee arthroplasty. The contributions of muscle
atrophy and failure of voluntary muscle activation. J
Bone Joint Surg Am. 2005; 87(5):1047-53.
6. Stevens JE, Mizner RL, Snyder-mackler L. Quadriceps
strength and volitional activation before and after
total knee arthroplasty for osteoarthritis. J Orthop
Res. 2003; 21(5):775-9.
7. Morrissey MC, Hudson ZL, Drechsler WI, Coutts FJ,
Knight PR, King JB. Effects of open versus closed
kinetic chain training on knee laxity in the early period
after anterior cruciate ligament reconstruction. Knee
Surg Sports Traumatol Arthrosc. 2000; 8(6):343-8.
8. Morrissey MC, Drechsler WI, Morrissey D, Knight PR,
Armstrong PW, Mcauliffe TB. Effects of distally fixated
versus nondistally fixated leg extensor resistance
training on knee pain in the early period after anterior
cruciate ligament reconstruction. Phys Ther. 2002;
82(1):35-43.
9. Fitzgerald GK. Open versus closed kinetic chain
exercise: issues in rehabilitation after anterior
cruciate ligament reconstructive surgery. Phys Ther.
1997; 77(12):1747-54.
10. Wegener L, Kisner C, Nichols D. Static and dynamic
balance responses in persons with bilateral knee
osteoarthritis. J Orthop Sports Phys Ther. 1997;
25(1):13-8.
11. Salter RB. The biologic concept of continuous passive
motion of synovial joints. The first 18 years of basic
research and its clinical application. Clin Orthop Relat
Res. 1989; 242(1):12-25.
12. Harvey LA, Brosseau L, Herbert RD. Continuous
passive motion following total knee arthroplasty in
people with arthritis. Cochrane Database Syst Rev.
2014; 6(2):CD004260.
13. Mcinnes J, Larson MG, Daltroy LH, Brown T, Fossel AH,
Eaton HM, et al. A controlled evaluation of continuous
passive motion in patients undergoing total knee
arthroplasty. JAMA. 1992; 268(11):1423-8.
14. Friemert B, V lübken F, Schmidt R, Jouini C, Gerngross
H. The influence of a controlled active motion splint
on proprioception after anterior cruciate ligament
plasty. A prospective randomized study. Unfallchirurg.
2006; 109(1):22-9.
15. Patil S, Colwell CW Jr, Ezzet KA, D’lima DD. Can normal
knee kinematics be restored with unicompartmental
knee replacement? J Bone Joint Surg Am. 2005;
87(2):332-8.
16. Arnold BL, Schmitz RJ. Examination of balance
measures produced by the biodex stability system. J
Athl Train. 1998; 33(4):323-7.
17. Hooper DM, Morrissey MC, Drechsler W, Morrissey
D, King J. Open and closed kinetic chain exercises
in the early period after anterior cruciate ligament
reconstruction. Improvements in level walking, stair
ascent, and stair descent. Am J Sports Med. 2001;
29(2):167-74.
18. Perry MC, Morrissey MC, King JB, Morrissey D,
Earnshaw P. Effects of closed versus open kinetic
chain knee extensor resistance training on knee laxity
and leg function in patients during the 8- to 14-week
post-operative period after anterior cruciate ligament
reconstruction. Knee Surg Sports Traumatol Arthrosc.
2005; 13(5):357-69.
19. Cachupe WJ, Shifflett B, Kahanov L, Wughalter EH.
Reliability of biodex balance system measures. Meas
Phys Educ Exerc Sci. 2001; 5(2):97-108.
20. Pincivero DM. Learning effects and reliability of
the Biodex Stability System. J Athl Train. 1995;
30(Suppl):S35.
21. Swanik CB, Lephart SM, Rubash HE. Proprioception,
kinesthesia, and balance after total knee arthroplasty
with cruciate-retaining and posterior stabilized
prostheses. J Bone Joint Surg Am. 2004; 86-A(2):328-34.
22. Gstoettner M, Raschner C, Dirnberger E, Leimser H,
Krismer M. Preoperative proprioceptive training in
patients with total knee arthroplasty. Knee. 2011;
18(4):265-70.
23. Lenssen AF, De Bie RA, Bulstra SK, Van Steyn MJ.
Continuous passive motion in rehabilitation following
total knee arthroplasty: a randomised controlled trial.
Physical Ther Rev. 2003; 8(3):123-9.
24. Koblbauer IF, Lambrecht Y, van der Hulst ML, Neeter
C, Engelbert RH, Poolman RW, et al. Reliability
of maximal isometric knee strength testing with
modified hand-held dynamometry in patients
awaiting total knee arthroplasty: useful in research
and individual patient settings? A reliability study.
BMC Musculoskelet Disord. 2011; 12(1):249.
25. Stark T, Walker B, Phillips JK, Fejer R, Beck R. Handheld
dynamometry correlation with the gold standard
isokinetic dynamometry: a systematic review. PM R.
2011; 3(5):472-9.
26. Barrett DS, Cobb AG, Bentley G. Joint proprioception
in normal, osteoarthritic and replaced knees. J Bone
Joint Surg Br. 1991; 73(1):53-6.
27. Wada M, Kawahara H, Shimada S, Miyazaki T, Baba H. Joint
proprioception before and after total knee arthroplasty.
Clin Orthop Relat Res. 2002; 403(1):161-7.