Comparison of Therapeutic Effects of Different Rehabilitation Methods on Patients Undergoing Total Knee Arthroplasty: A Network Meta-Analysis of Randomized Controlled Trials

Abstract

Objective: The rehabilitation methods after total knee arthroplasty (TKA) can affect the recovery of complications and joint function, and the selection and comparison of rehabilitation methods after TKA still need further research.

Methods: A comprehensive search of five databases and two clinical trial registration platforms was conducted from inception through March 31, 2024, and conducted to identify eligible randomized controlled trials (RCTs). We extracted the required data according to the Cochrane Handbook for Systematic Reviews of Interventions. Finally, 32 trials involving 2292 patients were included, the mean age of the enrolled patients was ∼69.10 years, the sex ratio of males was (31.6%), and the longest follow-up time was 2 years. And we have summarized nine rehabilitation intervention measures: conventional physical therapy (CPT), cryotherapy, thermal therapy (TT), acupuncture, hydrotherapy, neuromuscular training (NT), electrotherapy, continuous passive motion (CPM), continuous active motion (CAM). And use the range of motion (ROM), visual analog scale (VAS), Western Ontario and McMaster Universities osteoarthritis index (WOMAC) as the outcome measure to evaluate the effectiveness of various interventions. A Bayesian network meta-analysis (NMA) was carried out for calculating standardized mean difference (SMD) and the surface under cumulative ranking curve (SUCRA) of improvement of knee joint function after TKA by different rehabilitation methods.

Result: After treatment, the ROM results showed that cryotherapy, electrotherapy, and NT had better therapeutic effects. Among them, cryotherapy (WMD = 10.3, 95% CI 1.63–18.2) had a significant therapeutic effect. In terms of VAS, NT and TT showed good therapeutic effects. Among them, NT had a more significant therapeutic effect, while CAM had less effect. After treatment, in terms of WOMAC, TT, hydrotherapy, cryotherapy, and NT had better therapeutic effects. TT had the best therapeutic effect, while Hydrotherapy and Cryotherapy also had certain advantages.

Conclusion: NT, TT, cryotherapy, hydrotherapy, and electrotherapy rehabilitation therapies have good therapeutic effects for TKA patients compared with other interventions. Among them, NT may be the best postoperative rehabilitation therapy.

Keywords

cryotherapy / network meta-analysis / neuromuscular training / rehabilitation / TKA

References

[1] Z. Chen, Z. Shen, X. Ye, J. Wu, H. Wu, and X. Xu, “Association Between Foot Posture Asymmetry and Static Stability in Patients With Knee Osteoarthritis: A Case-Control Study,” BioMed Research International 2020 (2020): 1–8,

[2] B. U. Nwachukwu, K. J. Bozic, W. W. Schairer, et al., “Current Status of Cost Utility Analyses in Total Joint Arthroplasty: A Systematic Review,” Clinical Orthopaedics and Related Research 473 (2015): 1815–1827,

[3] D. L. Judd, V. A. Cheuy, J. E. Forster, C. L. Christiansen, and J. E. Stevens-Lapsley, “Incorporating Specific Functional Strength Integration Techniques to Improve Functional Performance for Veterans After Total Hip Arthroplasty: Protocol for a Randomized Clinical Trial,” Physical Therapy 99 (2019): 1453–1460,

[4] A. Patel, G. Pavlou, R. E. Mújica-Mota, and A. D. Toms, “The Epidemiology of Revision Total Knee and Hip Arthroplasty in England and Wales: A Comparative Analysis With Projections for the United States. A Study Using the National Joint Registry Dataset,” Bone & Joint Journal 97 (2015): 1076–1081,

[5] D. F. Hamilton, N. D. Clement, R. Burnett, et al., “Do Modern Total Knee Replacements Offer Better Value for Money? A Health Economic Analysis,” International Orthopaedics (SICOT) 37 (2013): 2147–2152,

[6] R. Meneghini, G. Russo, and J. Lieberman, “Modern Perceptions and Expectations Regarding Total Knee Arthroplasty,” Journal of Knee Surgery 27 (2013): 93–98,

[7] K. D. Allen and Y. M. Golightly, “State of the Evidence,” Current Opinion in Rheumatology 27 (2015): 276–283,

[8] S. Adie, J. M. Naylor, and I. A. Harris, “Cryotherapy After Total Knee Arthroplasty,” Journal of Arthroplasty 25 (2010): 709–715,

[9] H. J. Gerbershagen, S. Aduckathil, A. J. M. Van Wijck, et al., “Pain Intensity on the First Day After Surgery,” Anesthesiology 118 (2013): 934–944,

[10] B. Holm, H. Husted, H. Kehlet, and T. Bandholm, “Effect of Knee Joint Icing on Knee Extension Strength and Knee Pain Early After Total Knee Arthroplasty: A Randomized Cross-Over Study,” Clinical Rehabilitation 26 (2012): 716–723,

[11] M. J. Bade, W. M. Kohrt, and J. E. Stevens-Lapsley, “Outcomes Before and After Total Knee Arthroplasty Compared to Healthy Adults,” Journal of Orthopaedic and Sports Physical Therapy 40 (2010): 559–567,

[12] J. E Stevens-Lapsley, J. E. Balter, W. M. Kohrt, and D. G. Eckhoff, “Quadriceps and Hamstrings Muscle Dysfunction After Total Knee Arthroplasty,” Clinical Orthopaedics and Related Research 468 (2010): 2460–2468,

[13] J. Mclnnes, “A Controlled Evaluation of Continuous Passive Motion in Patients Undergoing Total Knee Arthroplasty,” JAMA 268 (1992): 1423–1428,

[14] B. Chen, J. R. Zimmerman, L. Soulen, and J. A. DeLisa, “Continuous Passive Motion After Total Knee Arthroplasty: A Prospective Study,” American Journal of Physical Medicine & Rehabilitation 79 (2000): 421–426,

[15] A. Ruffilli, F. Castagnini, F. Traina, et al., “Temperature-Controlled Continuous Cold Flow Device After Total Knee Arthroplasty: A Randomized Controlled Trial Study,” Journal of Knee Surgery 30 (2017): 675–681,

[16] V. Bruun-Olsen, K. E. Heiberg, and A. M. Mengshoel, “Continuous Passive Motion as an Adjunct to Active Exercises in Early Rehabilitation Following Total Knee Arthroplasty – A Randomized Controlled Trial,” Disability and Rehabilitation 31 (2009): 277–283,

[17] M. Amir-Behghadami and A. Janati, “Population, Intervention, Comparison, Outcomes and Study (PICOS) Design as a Framework to Formulate Eligibility Criteria in Systematic Reviews,” Emergency Medicine Journal 37 (2020): 387,

[18] J. P. T Higgins, J. Thomas, J. Chandler, et al., eds., Cochrane Handbook for Systematic Reviews of Interventions (Chichester, UK: John Wiley & Sons, 2019).

[19] M. L. McHugh, “Interrater Reliability: The Kappa Statistic,” Biochemia Medica 22 (2012): 276–282.

[20] GitHub, “GitHub – gertvv/gemtc: GeMTC R package: model generation for network meta-analysis,” https://github.com/gertvv/gemtc.

[21] E. Flemyng, K. Dwan, T. H. Moore, et al., “Risk of Bias 2 in Cochrane Reviews: A Phased Approach for the Introduction of New Methodology,” Cochrane Database of Systematic Reviews 10 (2020): ED000148,

[22] S. Kim, F.-C. Hsu, L. Groban, J. Williamson, and S. Messier, “A Pilot Study of Aquatic Prehabilitation in Adults With Knee Osteoarthritis Undergoing Total Knee Arthroplasty – Short Term Outcome,” BMC Musculoskeletal Disorders 22 (2021): 388,

[23] C.-H. Huang, M.-L. Yeh, F.-P. Chen, and M. Kuo, “A Randomised Controlled Trial of Laser Acupuncture Improves Early Outcomes of Osteoarthritis Patients’ Physical Functional Ability After Total Knee Replacement,” Complementary Therapies in Clinical Practice 43 (2021): 101340,

[24] F. Domínguez-Navarro, A. Silvestre-Muñoz, C. Igual-Camacho, et al., “A Randomized Controlled Trial Assessing the Effects of Preoperative Strengthening Plus Balance Training on Balance and Functional Outcome Up to 1 Year Following Total Knee Replacement,” Knee Surgery, Sports Traumatology, Arthroscopy 29 (2021): 838–848,

[25] R. Dabadghav, A. Potdar, V. Patil, P. Sancheti, and A. Shyam, “Additional Effect of Neuromuscular Electrical Stimulation on Knee Extension Lag, Pain and Knee Range of Motion in Immediate Postsurgical Phase (0–2 Weeks) in Primary Total Knee Arthroplasty Patient,” Annals of Translational Medicine 7 (2019): S253,

[26] L. Chen, C. Chen, S. Lin, et al., “Aggressive Continuous Passive Motion Exercise Does Not Improve Knee Range of Motion After Total Knee Arthroplasty,” Journal of Clinical Nursing 22 (2013): 389–394,

[27] T. K. Kim, K. K. Park, S. W. Yoon, S. J. Kim, C. B. Chang, and S. C. Seong, “Clinical Value of Regular Passive ROM Exercise by a Physical Therapist After Total Knee Arthroplasty,” Knee Surgery, Sports Traumatology, Arthroscopy 17 (2009): 1152–1158,

[28] Y. Tsukada, H. Matsuse, N. Shinozaki, et al., “Combined Application of Electrically Stimulated Antagonist Muscle Contraction and Volitional Muscle Contraction Prevents Muscle Strength Weakness and Promotes Physical Function Recovery After Total Knee Arthroplasty: A Randomized Controlled Trial,” Kurume Medical Journal 65 (2018): 145–154,

[29] M. Levine, K. McElroy, V. Stakich, and J. Cicco, “Comparing Conventional Physical Therapy Rehabilitation With Neuromuscular Electrical Stimulation After TKA,” Orthopedics 36 (2013): e319–e324,

[30] E. Yuksel, B. Unver, and V. Karatosun, “Comparison of Kinesio Taping and Cold Therapy in Patients With Total Knee Arthroplasty: A Randomized Controlled Trial,” Clinical Rehabilitation 36 (2022): 359–368,

[31] F. Montgomery and M. Eliasson, “Continuous Passive Motion Compared to Active Physical Therapy After Knee Arthroplast:Similar Hospitalization Times in a Randomized Study of 68 Patients,” Acta Orthopaedica Scandinavica 67 (1996): 7–9,

[32] S. Gil-González, R. A. Barja-Rodríguez, A. López-Pujol, et al., “Continuous Passive Motion Not Affect the Knee Motion and the Surgical Wound Aspect After Total Knee Arthroplasty,” Journal of Orthopaedic Surgery and Research 17 (2022): 25,

[33] T. L. Jakobsen, H. Kehlet, H. Husted, J. Petersen, and T. Bandholm, “Early Progressive Strength Training to Enhance Recovery After Fast-Track Total Knee Arthroplasty: A Randomized Controlled Trial,” Arthritis Care & Research 66 (2014): 1856–1866,

[34] Z. O. Karaduman, O. Turhal, Y. Turhan, et al., “Evaluation of the Clinical Efficacy of Using Thermal Camera for Cryotherapy in Patients With Total Knee Arthroplasty: A Prospective Study,” Medicina 55 (2019): 661,

[35] N. Wirries, M. Ezechieli, K. Stimpel, and M. Skutek, “Impact of Continuous Passive Motion on Rehabilitation Following Total Knee Arthroplasty,” Physiotherapy Research International 25 (2020): e1869,

[36] S. Hardt, M. R. G. Schulz, T. Pfitzner, et al., “Improved Early Outcome After TKA Through an App-Based Active Muscle Training Programme—A Randomized-Controlled Trial,” Knee Surgery, Sports Traumatology, Arthroscopy 26 (2018): 3429–3437,

[37] A. K. Klika, G. Yakubek, N. Piuzzi, G. Calabrese, W. K. Barsoum, and C. A. Higuera, “Neuromuscular Electrical Stimulation Use After Total Knee Arthroplasty Improves Early Return to Function: A Randomized Trial,” Journal of Knee Surgery 35 (2022): 104–111,

[38] S. J. MacDonald, R. B. Bourne, C. H. Rorabeck, et al., “Prospective Randomized Clinical Trial of Continuous Passive Motion After Total Knee Arthroplasty,” Clinical Orthopaedics and Related Research 380 (2000): 30–35,

[39] J. A. Herbold, K. Bonistall, M. Blackburn, et al., “Randomized Controlled Trial of the Effectiveness of Continuous Passive Motion After Total Knee Replacement,” Archives of Physical Medicine and Rehabilitation 95 (2014): 1240–1245,

[40] M. Schulz, B. Krohne, W. Röder, and K. Sander, “Randomized, Prospective, Monocentric Study to Compare the Outcome of Continuous Passive Motion and Controlled Active Motion After Total Knee Arthroplasty,” Technology and Health Care 26 (2018): 499–506,

[41] S. Karaborklu Argut, D. Celik, and O. I. Kilicoglu, “The Combination of Exercise and Manual Therapy Versus Exercise Alone in Total Knee Arthroplasty Rehabilitation: A Randomized Controlled Clinical Trial,” Physical Medicine and Rehabilitation 13 (2021): 1069–1078,

[42] A. Mau-Moeller, M. Behrens, S. Finze, S. Bruhn, R. Bader, and W. Mittelmeier, “The Effect of Continuous Passive Motion and Sling Exercise Training on Clinical and Functional Outcomes Following Total Knee Arthroplasty: A Randomized Active-Controlled Clinical Study,” Health and Quality of Life Outcomes 12 (2014): 68,

[43] R. N. Maniar, J. V. Baviskar, T. Singhi, and S. S. Rathi, “To Use or Not to Use Continuous Passive Motion Post-Total Knee Arthroplasty,” Journal of Arthroplasty 27 (2012): 193–200,

[44] C.-C. Chen, C.-C. Yang, C.-C. Hu, H. N. Shih, Y. H. Chang, and P. H. Hsieh, “Acupuncture for Pain Relief After Total Knee Arthroplasty: A Randomized Controlled Trial,” Regional Anesthesia and Pain Medicine 40 (2015): 31–36,

[45] M. García-Marín, D. Rodríguez-Almagro, Y. Castellote-Caballero, A. Achalandabaso-Ochoa, R. Lomas-Vega, and A. J. Ibáñez-Vera, “Efficacy of Non-Invasive Radiofrequency-Based Diathermy in the Postoperative Phase of Knee Arthroplasty: A Double-Blind Randomized Clinical Trial,” Journal of Clinical Medicine 10 (2021): 1611,

[46] A. Valtonen, T. Pöyhönen, S. Sipilä, and A. Heinonen, “Effects of Aquatic Resistance Training on Mobility Limitation and Lower-Limb Impairments After Knee Replacement,” Archives of Physical Medicine and Rehabilitation 91 (2010): 833–839,

[47] C.-D. Liao, T.-H. Liou, Y.-Y. Huang, and Y.-C. Huang, “Effects of Balance Training on Functional Outcome After Total Knee Replacement in Patients With Knee Osteoarthritis: A Randomized Controlled Trial,” Clinical Rehabilitation 27 (2013): 697–709,

[48] P. J. Hecht, S. Bachmann, R. E. Booth, and R. H. Rothman, “Effects of Thermal Therapy on Rehabilitation After Total Knee Arthroplasty. A Prospective Randomized Study,” Clinical Orthopaedics and Related Research (1983): 198–201.

[49] A. M. Alonso-Rodríguez, H. Sánchez-Herrero, S. Nunes-Hernández, B. Criado-Fernández, S. González-López, and M. Solís-Muñoz, “Efficacy of Hydrotherapy Versus Gym Treatment in Primary Total Knee Prosthesis due to Osteoarthritis: A Randomized Controlled Trial,” Anales del Sistema Sanitario de Navarra 44 (2021): 225–241,

[50] A. Barbieri, K. Vanhaecht, P. Van Herck, et al., “Effects of Clinical Pathways in the Joint Replacement: A Meta-Analysis,” BMC Medicine 7 (2009): 32,

[51] D. D. Price, P. A. McGrath, A. Rafii, and B. Buckingham, “The Validation of Visual Analogue Scales as Ratio Scale Measures for Chronic and Experimental Pain,” Pain 17 (1983): 45–56,

[52] S. E. Markert, “The Use of Cryotherapy After a Total Knee Replacement: A Literature Review,” Orthopaedic Nursing 30 (2011): 29–36,

[53] M. Ueyama, D. Takamura, R. Nakajima, et al., “Alterations in Deep Tissue Temperature Around the Knee After Total Knee Arthroplasty: Its Association With Knee Motion Recovery in the Early Phase,” Physical Therapy Research 21 (2018): 1–8,

[54] E. Thienpont, “Does Advanced Cryotherapy Reduce Pain and Narcotic Consumption After Knee Arthroplasty?,” Clinical Orthopaedics and Related Research 472 (2014): 3417–3423,

[55] A. A. Algafly and K. P. George, “The Effect of Cryotherapy on Nerve Conduction Velocity, Pain Threshold and Pain Tolerance,” British Journal of Sports Medicine 41 (2007): 365–369,

[56] A. M. Risso, M. L. Van Der Linden, A. Bailey, et al., “Exploratory Insights Into Novel Prehabilitative Neuromuscular Exercise-Conditioning in Total Knee Arthroplasty,” BMC Musculoskeletal Disorders 23 (2022): 547,

[57] K. G. Henderson, J. A. Wallis, and D. A. Snowdon, “Active Physiotherapy Interventions Following Total Knee Arthroplasty in the Hospital and Inpatient Rehabilitation Settings: A Systematic Review and Meta-Analysis,” Physiotherapy 104 (2018): 25–35,

[58] F. Pozzi, D. K. White, L. Snyder-Mackler, and J. A. Zeni, “Restoring Physical Function After Knee Replacement: A Cross Sectional Comparison of Progressive Strengthening vs Standard Physical Therapy,” Physiotherapy Theory and Practice 36 (2020): 122–133,

[59] D. A. Rice and P. J. McNair, “Quadriceps Arthrogenic Muscle Inhibition: Neural Mechanisms and Treatment Perspectives,” Seminars in Arthritis and Rheumatism 40 (2010): 250–266,

[60] T. J. Suchomel, S. Nimphius, C. R. Bellon, and M. H. Stone, “The Importance of Muscular Strength: Training Considerations,” Sports Medicine 48 (2018): 765–785,

[61] P. Aagaard, E. B. Simonsen, J. L. Andersen, S. P. Magnusson, J. Halkjær-Kristensen, and P. Dyhre-Poulsen, “Neural Inhibition During Maximal Eccentric and Concentric Quadriceps Contraction: Effects of Resistance Training,” Journal of Applied Physiology 89 (2000): 2249–2257,

[62] W. H. Gage, J. S. Frank, S. D. Prentice, and P. Stevenson, “Organization of Postural Responses Following a Rotational Support Surface Perturbation, After TKA: Sagittal Plane Rotations,” Gait & Posture 25 (2007): 112–120,

[63] Á. Pethes, Z. Bejek, and R. M. Kiss, “The Effect of Knee Arthroplasty on Balancing Ability in Response to Sudden Unidirectional Perturbation in the Early Postoperative Period,” Journal of Electromyography and Kinesiology 25 (2015): 508–514,

[64] B. Kumaran and T. Watson, “Thermal Build-Up, Decay and Retention Responses to Local Therapeutic Application of 448 kHz Capacitive Resistive Monopolar Radiofrequency: A Prospective Randomised Crossover Study in Healthy Adults,” International Journal of Hyperthermia 31 (2015): 883–895,

[65] M. Albornoz-Cabello, A. Ibáñez-Vera, M. Aguilar-Ferrándiz, and L. Espejo-Antúnez, “Monopolar Dielectric Diathermy by Emission of Radiofrequency in Patellofemoral Pain. A Single-Blind-Randomized Clinical Trial,” Electromagnetic Biology and Medicine 39 (2020): 282–289,

[66] D. Tedesco, D. Gori, K. R. Desai, et al., “Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis,” JAMA Surgery 152 (2017): e172872,

[67] W. Meier, R. Mizner, R. Marcus, L. Dibble, C. Peters, and P. C. Lastayo, “Total Knee Arthroplasty: Muscle Impairments, Functional Limitations, and Recommended Rehabilitation Approaches,” Journal of Orthopaedic and Sports Physical Therapy 38 (2008): 246–256,

[68] J. E Stevens-Lapsley, J. E. Balter, P. Wolfe, et al., “Relationship Between Intensity of Quadriceps Muscle Neuromuscular Electrical Stimulation and Strength Recovery After Total Knee Arthroplasty,” Physical Therapy 92 (2012): 1187–1196,

[69] B. Monaghan, B. Caulfield, and D. P. O’Mathúna, “Surface Neuromuscular Electrical Stimulation for Quadriceps Strengthening Pre and Post Total Knee Replacement,” Cochrane Database of Systematic Reviews 2010 (2010): CD007177,

[70] A. Delitto, M. J. Strube, A. D. Shulman, and S. D. Minor, “A Study of Discomfort With Electrical Stimulation,” Physical Therapy 72 (1992): 410–421,

[71] S. Giaquinto, E. Ciotola, V. Dall’Armi, and F. Margutti, “Hydrotherapy After Total Knee Arthroplasty. A Follow-Up Study,” Archives of Gerontology and Geriatrics 51 (2010): 59–63,

[72] A. Mooventhan and L. Nivethitha, “Scientific Evidence-Based Effects of Hydrotherapy on Various Systems of the Body,” North American Journal of Medical Sciences 6 (2014): 199–209,

[73] J. Naylor, A. Harmer, M. Fransen, J. Crosbie, and L. Innes, “Status of Physiotherapy Rehabilitation After Total Knee Replacement in Australia,” Physiotherapy Research International 11 (2006): 35–47,

[74] X. Yang, G. Li, H. Wang, and C. Wang, “Continuous Passive Motion After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Associated Effects on Clinical Outcomes,” Archives of Physical Medicine and Rehabilitation 100 (2019): 1763–1778,

RIGHTS & PERMISSIONS

2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.