What is Total Hip/Knee Replacement Rehabilitation

A total hip or knee replacement (THR/TKR) surgery is typically done when severe arthritis causes hip or knee pain, limiting range of motion, and making it extremely difficult to walk pain-free. Physical therapy can help both before and after your surgery to improve outcomes and ensure that you have a predictable recovery.

Trusted Partnerships

Vaughan Physiotherapy Clinic is proud to be a trusted partner with North York General, Women’s College, Mackenzie Health, and Markham Stouffville Hospital. We have a wealth of experience when it comes to taking care of patients coming out of total knee arthroplasty. Our clinicians follow the most up to date knee replacement physio protocols and evidence to guide rehabilitation.

We communicate with the hospital systems regularly to ensure a smooth programme from inpatient to outpatient rehabilitation and promote good outcomes for all patients.

What do I need to know about post-operative Hip rehabilitation at Vaughan Physiotherapy Clinic?

1. Exercises

Physical therapists should design, implement, teach, and progress patients who have undergone THA in high-intensity strength training and exercise programs during the early post acute period (ie, within 7 days after surgery) to improve function, strength, and ROM.

- Evidence Quality: High; Recommendation Strength: Moderate
- Open/closed chain, +/- resistance, circuits, bike

2. Functional Activities

Physical therapists should design, implement, teach, and progress patients who have undergone THA in high-intensity strength training and exercise programs during the early post acute period (ie, within 7 days after surgery) to improve function, strength, and ROM.

- Evidence Quality: High; Recommendation Strength: Moderate
- Gait retraining, stairs, sit-to-stand

3. Manual therapy

Physical therapists should include manual therapy for pain management and neuromuscular facilitation for patients who have undergone TKA.

- Evidence Quality: Medium; Recommendation Strength: Weak
- Massage, patella mobilizations

4. Stretches

Physical therapists should include stretching.

- Evidence Quality: High; Recommendation Strength: Moderate
- Self/assisted hip flexors, extensors, knee flexors, extensors etc.

5. Swelling/pain management (ice, bandaging, interferential)

Physical therapists should teach and encourage use of cryotherapy for early postoperative pain management for patients who have undergone THA.

- Evidence Quality: High; Recommendation Strength: Moderate.

Physical therapists should use neuromuscular electrical stimulation (NMES) for patients who have undergone THA to improve quadriceps strength, gait performance, performance-based outcomes, and patient-reported outcomes.

- Evidence Quality: High; Recommendation Strength: Moderate

6. Education

Supervised physical therapist management should be provided for patients who have undergone THA. The optimal setting should be determined by patient safety, mobility, environmental, and personal factors.

- Evidence Quality: Moderate; Recommendation Strength: Moderate

6. Pre-Operative Rehabilitation

The best time to start your rehabilitation is before your surgery. There are many studies supporting the use of preoperative physical therapy training/exercise programs for patients undergoing a Total Hip Replacement and are associated with better post-operative functional outcomes.Physical therapists should design preoperative exercise programs and teach patients undergoing total knee arthroplasty (THA) to implement strengthening and flexibility exercises.

- Evidence Quality: High; Recommendation Strength: Moderate

A 2020 meta-analysis showed that:
• Length of inpatient stay was reduced with preoperative training.
• Knee flexion & extension range of motion (ROM) improved at 3 months postoperative with preoperative training.
• Quadriceps strength improved at 1- and 3-months post surgery with preoperative quadriceps training.
• Isometric hip abduction, knee flexion & extension strength improved at 1- and 3-months post surgery with preoperative training.
• Fewer postoperative days were required to reach 90 degrees of knee flexion with preoperative exercise.

Benefits are as follows:
• Improved activities
• Decreased pain
• Improved balance
• Improved knee flexion ROM
• Improved knee extension ROM
• Improved isometric knee and hip strength
• Improved report of quality of life (eg, as measured by SF-36)
• Reduced length of stay of inpatient stay

Risk, harm, and/or cost are as follows:
• No reported harms were associated with implementing this recommendation.
• Team members should be aware of potential complications after TKA that may affect exercise including incision healing, thromboembolism, and joint stiffness/arthrofibrosis. While costs were not reported in studies, there may be an expected associated expense.

What to expect after your operation

Day 1 Post-Op

The first day out of your surgery you will be guided through rehab in the hospital. Usually, a physical therapist there will help you begin mobilising (e.g. getting out of bed, beginning to walk, etc.) If necessary, you will be given a 4 wheeled walker to assist you with walking.

The therapist will guide you through several preliminary hip exercises at the hospital on day one. This is important as it will improve your hip mobility and strength so that you may begin to walk sooner.

Certain exercises such as ankle pumps and leg squeezes prevent blood from pooling in the lower limb. This can reduce the risk of developing a deep vein thrombosis (DVT) which can be potentially life threatening.

The number one goal is to become independent and functionally mobile so that you can leave the hospital and go home. This means you should be able to move in bed, get out of bed, and walk around independently.

Post-Op Weeks 1-2

Typically, your stay at the hospital will be 48-72 hours, and you should have good functional mobility at this stage. The hospital may either discharge you to your home or a sub-acute rehabilitation facility depending on your status.

Sub-Acute Rehabilitation

Sometimes patients will require additional care and be transferred to a sub-acute rehabilitation facility such as Toronto Rehabilitation Institute or Bridgepoint Health.

These facilities will help you regain your strength and mobility so that you are able to return home safely and independently.

A sub-acute rehabilitation stay lasts between 7-14 days depending on an individual’s needs.

Your days will likely consist of intensive physiotherapy – 1-2 sessions/day.

Returning Home

Once you are cleared to return home from the hospital you may choose to have either

1. home-care physical therapist come to your home or

2. travel to an outpatient physical therapy facility

Home-care physical therapy is usually reserved for patients who are not able to travel, and for those who require assistance in the home.

Outpatient physical therapy facilities will help you to safely regain your knee range of motion and guide you to build your strength back up. These facilities can document and log your progress and relay them back to your hospital and surgeon. You will be given a treatment plan and may attend these facilities 2-3 times per week to maximize your recovery. It is expected that you are adherent to a home exercise plan to recover fully.

At the end of Week 2 Post-Op, you should be able to bend your knee to 90 degrees.

Post-Op Weeks 3-6

At this stage in your recovery patients should be rehabbing at an outpatient physical therapy facility.

Here you will be guided by trained physical therapists through more aggressive range of motion, mobility, and resistance activities. We should see a gradual improvement in the knee’s range of motion to approximately 105 degrees by the end of 6 weeks.

Some activities that are common after a TKR surgery are:

- stationary bike
- static isometric exercises
- closed chain exercises
- functional activities
- balance exercises

There should be a strong focus on strengthening exercises after a THR surgery. Your physical therapist will guide you through these activities, ensuring proper form, and preventing risk of disrupting the joint.

Physical therapy will also involve the use of pain and oedema management modalities such as cryotherapy and compression to assist with inflammation and swelling.

Your therapist may also use something called neuromuscular electrical stimulation (NMES) to help improve muscular activation of certain muscle groups such as your quadriceps and hamstrings. This modality uses electrical current to help contract these muscle groups and improve your ability to do this yourself.

Your physical therapists will teach you how to walk again without the use of crutches. You will be guided through several progressions, initially with the help of the walker, then to crutches (1-2), and then a cane. The goal at the end of week 6 will be to walk independently without any assistive devices.

Post-Op Weeks 7-8

During this stage of your rehabilitation, you will be required to progress towards full independent mobility. The exercises should continue to focus on regaining the strength in the muscles around the knee and hip joint.

The exercises should challenge you however should not necessarily be painful. It is important to be consistent with your rehabilitation program to ensure good outcomes after surgery.

Once you are ready to be discharged your physical therapist will create a plan for continuing your exercise program independently. Many of these facilities will have stationary bikes and weight training equipment in order for you to continue your program.