Mc Avoy R (2009). Aquatic and land based therapy vs land therapy on the outcome of total knee arthroplasty a pilot randomized clinical trial

Background and Purpose: Currently, there is a lack of objective data that supports the effectiveness of combining aquatic physical therapy with land based therapy. The purpose of this study was to determine the effectiveness of combining aquatic physical therapy with land based therapy verses solely land based therapy on pain, range of motion (ROM), swelling, as well as symptoms and function via the KOOS questionnaire in 30 patients that have undergone unilateral TKA.

Subjects: 30 subjects who have undergone unilateral TKA were randomly assigned to either the integrated (aquatic and land) group, or the control (land) group (IS subjects in each group).

Methods: Outcomes measured for comparison included pain, swelling, ROM and in addition symptoms and function via the Knee Injury and Osteoarthritis Outcome Scores questionnaire (KOOS).

Results: Immediately after exercise cessation (6 weeks), a significant improvement of knee flexion ROM was observed in the integrated group. No effect was observed in pain, swelling, and KOOS. At 6-months after cessation of treatment, the follow-up KOOS questionnaire demonstrated a significant improvement in the symptomatic category favoring the integrated group.

Conclusion: These findings suggest that after undergoing a unilateral TKAan individual would benefit from a treatment program consisting of both aquatic and land exercises that would greatly encourage improvements in ROM after a 6-weeks as well as improved symptomatic KOOS reports after 6-months.


Research Report

Aquatic andLand Based Therapy vs.Land
Therapy onthe Outcome ofTotal Knee
Arthroplasty: APilot Randomized ClinicalTrial

Richard McAvoy,
Richard McAvoy, PT,OPT, CSCS, isAquatic Program
Director, Rehab3at Marsh Brook, Center forAquatics,
Somersworth, NH.Address allcorrespondence toDr.
This research studywasconducted atRehab 3at
Marshbrook, Somersworth, NH.IRBapproval was
granted bythe Patient Advocacy Council,Inc.,Mobile,
AL. This study wasfunded byThe Foundation for
Physical Therapy withagenerous donationfromthe
National SpaandHotTub Council.
Abstract Background andPurpose: Currently, thereisalack of
objective datathatsupports theeffectiveness ofcombin-
ing aquatic physical therapywithlandbased therapy. The
purpose ofthis study wastodetermine theeffectiveness
of combining aquaticphysical therapywithlandbased
therapy versessolelylandbased therapy onpain, range of
motion (ROM), swelling, aswell assymptoms andfunction
via the KOOS questionnaire in30 patients thathave under-
gone unilateral TKA.Subjects: 30subjects whohave under-
gone unilateral TKAwere randomly assignedtoeither the
integrated (aquaticandland) group, orthe control (land)
group (ISsubjects ineach group). Methods: Outcomes
measured forcomparison includedpain,swelling, ROM
and inaddition symptoms andfunction viathe Knee Injury
and Osteoarthritis OutcomeScoresquestionnaire (KOOS).
Results: Immediately afterexercise cessation (6weeks), a
significant improvement ofknee flexion ROMwasob-
served inthe integrated group.Noeffect wasobserved in
pain, swelling, andKOOS. At6-months aftercessation of
treatment, thefollow-up KOOSquestionnaire demonstrat-
ed asignificant improvement inthe symptomatic category
favoring theintegrated groupConclusion: Thesefindings
suggest thatafter undergoing aunilateral TKAanindividual
would benefit fromatreatment programconsisting ofboth
aquatic andland exercises thatwould greatly encourage
improvements inROM aftera6-weeks aswell asimproved
symptomatic KOOSreports after6-months.
Key Words: pain,swelling, KOOS,rangeofmotion, aquatic
Total KneeArthroplasty (TKA)continues todemonstrate
success inrelieving kneepainandimproving functionfor
patients suffering fromkneepainsecondary toinjury and degenerative
jointdisease. 1The number ofTKAsperformed
each yearinthe United Statescontinues toincrease incre-
mentally. Atotal of160,000 TKAswereperformed inthe
United Statesin1991. In1994, thenumber ofprocedures
rose to210,000 resulting inhealthcare costsexceeding $5
billion.2 Datacollected in2004 continued todemonstrate
a significant increaseinthe number ofTKAs performed,
which roseannually to478,000. Astudy presented atthe
2006 Annual Meeting ofAmerican AcademyofOrtho-
paedic Surgeons projected a673% increase to34.8 million
surgeries performed annuallybythe year 2030. Thereare
a number offactors contributing tothis increase which
include theincreasingly agingpopulation, theobesity
epidemic, andtheindication forTKA extending toyounger
individuals aswell asapopulation thatdesires tostay more
physically active.
The most common symptoms apatient experiences after
undergoing aTKA arepain, swelling, stiffness,muscle
weakness andlimited ADL'S.Traditional landbased physi-
cal therapy rehabilitation forpatients following aTKA typi-
cally involves somecombination ofactive assistive range
of motion, strengthening, ADL,gaittraining, functional
training andpatient education.3 Numerousstudieshave
been performed onthe effectiveness ofland based physical
therapy following TKA.4-11
Aquatic Physical Therapy mayoffer analternative interven-
tion totraditional PhysicalTherapy Rehabilitation following
TKA.12 Therearemany reported benefitsofAquatic Physical
Therapy. Aquaticstudieshaveshown improvements inRO M,
swelling, painreduction, stiffnessandquality oflife after
TKA. However, thesestudies wereprimarily casestudy in
nature orwere notcompared toanother formoftreatment. 2,13
Currently, there'sapaucity ofliterature investigating the
therapeutic benefitsofutilizing anintegrated (aquaticand
land) rehabilitation protocolforindividuals whohave un-
dergone aTKA.14Therefore, thepurpose ofthis study was
to investigate theeffectiveness ofan integrated treatment
approach including aquaticwithlandbased therapy verses
land therapy aloneinimproving rangeofmotion, pain,
swelling, andfunctional statusinpatients withunilateral
TKA duetoOA.
This randomized clinicaltrialwasconducted betweenMay
2005 andJuly 2006 atRehab 3at Marshbrook inSomer-

sworth NewHampshire. Consecutivesubjectswerereferred
to physical therapybyone oftwo orthopedic surgeonsafter
undergoing aunilateral TKAwithin theprevious sixweeks.

Inclusion Criteria

1. Subjects between the50and 80years ofage.
2. Surgery wasperformed byone oftwo participating
orthopedic surgeons.
3. Subjects hadundergone unilateralTKAsecondary
to osteoarthritis.

Exclusion Criteria

1. Red flags noted inthe patient's admission medical
questionnaire. I.e.cardiac
Precautions, previousjointreplacements, etc.
2. Extremely fearfulofwater.
3. Bilateral TKA.
4. Insurance limitations notallowing themtoparticipate in
aquatic andland based thesame treatment session.
5. Inability tocomply withthetreatment or
follow-up schedule.
All patients thatmeteligibility criteriaandagreed topar-
ticipate inthe study signed aconsent formapproved by
the IRB. This study wasapproved bythe Patient Advocacy
Council's Institutional ReviewBoard,Mobile, AL.
All participating subjectsunderwent astandardized his-
tory, physical examination andcompleted anumber of
self-report measures. Thehistory anddifferential diag-
nosis wascompleted bythe lead author (RM)forallsub-
jects. Thehistory included astandard patienthistoryform
that each subject completed toflag anycontraindication
to subject participation. Thelead author alsoobtained a
self-report measureofpain aswell asthe administration
of the Knee Osteoarthritis OutcomeScore(KOOS) used
to measure subject'sbaselinefunctional status.Base-
line measurements ofactive andpassive kneerange of
motion, andgirth measurements wereobtained byone oftwo
blinded DataCollection Technicians (DCT)whowere both
physical therapists employed40hours perweek atRehab 3
at Marshbrook.
Numeric PainRating Scale(NPRS): Anll-point NPRS
ranging from0-10,0being described as"no pain atall"
and 10being "theworst painimaginable:' Patientsrated
their current levelofpain, andtheNPRS exhibits ahigh
testretest reliabilityofnumeric painrating scales(r=0.75
- r=0.83; pO.OOl)Y A2point change onthe NPRS isnec-
essary toexceed bounds ofmeasurement errorandtobe
considered clinicallymeaningful.

Circumferential Measurements:Circumferential measure-
ments ofthe knee were taken withthepatient inasupine
position. Measurements weretaken byone oftwo DCT's
that were blinded tothe subject groupassignment. Thelandmarks
thatwere evaluated aremid-patella, 3"proximal
to the center ofthe patella, and6"distal tothe center of
the patella. Allmeasurements weretaken withthesame
non-elastic tapemeasure. Reliability oflower extremity
girth measurement withanon-elastic tapemeasure fol-
lowing kneesurgery hasbeen documented byRoss and
Worrell whichdemonstrated excellentreliability forintra-
session andinter-session testing(ICC.90)Y Additionally,
a pilot study investigating thereliability ofcircumferential
measurements ofthe DCT's forthis study wasperformed.
Data wasanalyzed utilizingStatistical Packageforthe Social
Sciences Version13using anintra-class correlation coeffi-
cient (2,1). This pilot study demonstrated excellentinter-
rater reliability forgirth measurements ofthe mid-patella,
3 inches proximal tothe mid-patella, and6inches distalto
the mid-patella (0.994,95%CI0.989-0.997).
Range ofMotion (ROM): Bothknee active ROMand
passive ROMwastaken byone oftwo blinded DCT's.
Measurements weretaken withastandard plasticgoniom-
eter with thesubjects insupine. Thetesting procedure used
in this study hasbeen described byNorkin
marks usedformeasurement werethegreater trochanter
of the femur, headoffibula, andlateral malleolus. Patients
were instructed toslide hisher heeltowards thebuttocks,
bending theknee totheir subjective reportedtolerance
to discomfort ofthe procedure; ameasurement wasthen
taken andrecorded. TheDCT's theninstructed patient
to relax while applying agentle passive overpressure into
flexion againtothe patient's subjective reportedtolerance
to the discomfort ofthe procedure; anothermeasurement
of knee flexion wasthen taken andrecorded. Withthe
patient remaining inthe supine position, thesame proce-
dure wasused toobtain aknee extension measurement. The
reliability andvalidity ofthe goniometric measurements
has been documented inastudy byGogia, andBraatz,
inter- testreliability (r=.98;ICC=.99) andvalidity (r=.97-.98;
ICC= .98-.99) werehigh.
Additionally, apilot study in-
vestigating theinter-rater reliabilityofrange ofmotion
measurements ofthe DCT's forthis study wasperformed to
assure thatreliability ofmeasurements wouldbeadequate.
Data wasanalyzed utilizingStatistical Packageforthe So-
cial Sciences Version13using anintra-class correlation
coefficient (2,1). The results ofthis pilot study demon-
strated excellent inter-rater reliabilityforactive flexion
(0.99,95% CI0.987-0.998), passiveflexion (0.993,95% CI
0.981-0.997), activeextension (0.935,95% CI0.870-0.968),
and passive extension (0.934,95%CI0.868-0.968).
Knee Osteoarthritis OutcomeScore(KOOS): Subjectsshort
and long term symptoms aswell asfunction weremeasured
using theKOOS. Allparticipants ofthe study completed the
KOOS atbaseline, sixweeks, andreturned viamail atsix
months. TheKOOS indexisan extension ofthe Western
Ontario andMcMaster University Osteoarthritis Index
(WOMAC), themost commonly usedoutcome instru-
ment forassessment ofpatient's withrelevant injuryand
knee osteoarthritis. Previousstudieshavedemonstrated the

KOOS indextobe amore responsive instrument forknee
conditions comparedtothe WOMAC.20 TheKOOS holds
five separately scoredsubscales including pain,symptoms,
functiondaily living(ADL), functionsport recreation
(SPORTREC), andquality oflife (QOL). Forthepurpose
of this study, theSPORTREC componentofthe KOOS
was eliminated fromthesurvey duetothe intensity ofthe
activities inwhich thenature ofthe surgery wouldnotal-
low patients toperform, suchastwistingpivoting, kneeling,
and running onthe surgical knee.TheKOOS presents to
be valid, reliable, andresponsive selfadministered instru-
ment usedforshort andlong term follow-up ofseveral
orthopedic interventions suchasanterior cruciateligament
reconstruction, meniscectomy,andTKA.20 Thetestretest
reliability isacceptable forallsubscales andranges between
r=0.65-0.78 andthequestionnaire exhibitshighinternal
Randomization Randomization wasperformed usingarandom sequence
table generated bycomputer priortothe initiation ofthe
study. Group assignment wasputon3.5"x 5.5"card labeled
"Land" or"Water andLand" todenote groupassignment.
Each cardwasthen placed inaconcealed envelope.Eligible
patients thatparticipated inthis study wererandomly as-
signed toeither theland group orthe integrated groupby
the evaluating physicaltherapist thatchose oneofthe ran-
domization envelopes.
When designing theexercise programs foreach treatment
group attempts weremade bythe authors toselect exercises
that were similar innature butnotnecessarily performedin
the same medium. Thiswasdone inan attempt toequalize
treatment timesaswells asthe amount ofexercises between
Land Physical Therapy
Subjects randomly assignedtoparticipate inthe land group
received physicaltherapyonland twotimes aweek forsix
weeks. Themeasurements ofactive andpassive ROM,pain,
and girth measurements weretaken before andafter each
treatment sessionbyone oftwo blinded DCTs.TheKOOS
survey wascompleted byeach subject atbaseline, sixweeks,
and sixmonths. Eachlandpatient received sixtyminutes of
physical therapytwiceaweek forsixweeks. Landexercises
consisted ofvarious openandclosed chainlower extrem-
ity exercises emphasizing lowerextremity strength,balance,
proprioception, andactive andpassive rangeofmotion that
were alltimed withastop watch. RefertoAppendix Afor
land exercise protocol. Aone minute restperiod between
each exercise wasgiven aspatient needed.
Integrated PhysicalTherapy
Subjects randomly assignedtoparticipate inthe integrated
group received physicaltherapyinthe water andonland
two times aweek forsixweeks. Measurements ofactive
and passive ROM,pain,andgirth weretaken before and
after eachtreatment sessionbyablinded DCT's.TheKOOS survey
wascompleted byeach subject atbaseline, sixweeks,
and sixmonths. Patientsreceived 30minutes ofaquatic
therapy ina92 therapeutic poolfollowed by30minutes
of land physical therapy. Patientsinthe integrated group
were given 15minutes tochange between aquaticandland
therapy sessions. Landandaquatic exercises consisted of
various openandclosed chainlower extremity exercises
emphasizing lowerextremity strength,balance,propriocep-
tion, andactive andpassive rangeofmotion, andallexer-
cises performed werealltimed withastop watch. Referto
Appendix Bfor integrated exerciseprotocol. Aone min-
ute rest period between eachexercise wasgiven aspatient
Data Analysis
Data collected inthis study wasanalyzed usingtheRProject
for Statistical Computing. Baselinedemographics andout-
come measures wereanalyzed usingatwo-sample t-testto
detect between-group differences,andtheWilcoxon Rank-
Sum Testwasused asan alternative measurement forcases
where thedata didnot have anormal distribution. The
Wilcoxon Rank-Sum testisanonparametric testtoexam-
ine both thedirection ofdifference andtherelative amount
of difference betweentwodependent variables.22 Baseline
measurements ofthe dependent variablecompared inthis
study included: painlevel, active ROMkneeflexion, active
ROM kneeextension, passiveROMkneeflexion, passive
ROM kneeextension, girthmeasurement mid-patella,6
inches distaltothe mid-patella, and3inches proximal to
the mid-patella, aswell asFunction viathe KOOS. Com-
ponents ofthe KOOS usedforcomparison include:Pain,
Symptoms, ActivitiesofDaily Living, andQuality ofLife. A
P value ofP.05 wasconsidered statistically significantfor
all data analyzed.
Comparison ofchange frombaseline todischarge (visit
1 to visit 12)ofthe dependent variablesinthis study was
analyzed usingthetwo-sample t-test and Analysis ofcovari-
ance (ANCOVA). Thetwo-sample t-testwasused todetect
between-group differenceswhiletheANCOVA wasused to
equate groups onextraneous variablesandtocorrect for
heterogeneity amongpatients.
The four components ofthe KOOS investigated inthis study
were analyzed usingthetwo-sample t-testandWilcoxon
Rank-Sum Testtocompare outcome scoresfrombaseline
to discharge. Pair-wisedifferences forallsubjects wereob-
tained (measurement atdischarge minusmeasurement at
baseline), andthemeans ofthese "change inmeasurement"
values wereusedforcomparison betweenthetwo treatment
groups. AP-value of.05 orless isconsidered astatistically
significant changeinoutcome scores.
From May2005 toJuly 2006, 30subjects satisfied theeligi-
bility criteria, agreedtoparticipate andprovided informed
consent. Fifteensubjects wererandomly assignedtothe
integrated treatmentgroup,and15tothe control group.A

flow diagram ofsubject recruitment andretention canbe
found infigure 1.All patients withunilateral TKAreferred
to physical therapyagreedtoparticipate andcompleted
all components ofthe study including the6month KOOS
follow-up. Baselinevariables including pain,ROM, swell-
ing, andKOOS foreach group inthis study aresummarized
in table 1.Significant differenceswerefound among the
two groups forafew ofthe baseline variables measure. The
integrated groupbegan therapy atalower levelthan thatof
the land group. Differences inbaseline measurements to
include pain,ROM, andswelling wereequated byanalyz-
ing the data using theANCOVA. Baselinemeasurements of
the KOOS demonstrate significantdifferences betweenthe
groups forallcomponents withtheexception ofthe symp-
toms score (p=.02l). Dataanalysis demonstrated higher
KOOS function ratinginthe control groupatbaseline as
compared tothe integrated treatmentgroup.Uneven dis-
tribution ofbaseline KOOSmeasurements wascorrected
for using theWilcoxon Rank-Sum Test.
P values forchange independent measuresbetweengroups
from visit1to visit 12including pain,swelling andROM is
summarized inTable 2.Analysis ofthese dependent vari-
ables including pain,swelling, andknee extension ROM
from visit1to visit 12resulted inno significant differencebe-
tween groups, however significant differencewasfound for
knee flexion ROM(P=.045) favoringtheintegrated group.
Table 3shows thePvalues forallmeasured components
of the KOOS (baseline, 6weeks, and6months). Comparison
of KOOS frombaseline to6weeks resulted inno significant
difference inall categories, howeverastatistically significant
difference wasfound inthe Symptoms scorefavoring the
integrated treatmentgroup(p=.03) from 6weeks to
6 months.
This randomized clinicaltrialinvestigated theeffectiveness
of combining anaquatic andland based program verses
solely aland based program forthe treatment ofunilateral
TKA. Thisstudy demonstrated thata6-week integrated
physical therapyprogram improved kneeflexion ROMas
well KOOS Symptomatic reportswhichincluded swelling,
grinding, clicking,bending andstraightening theknee fully
after 6months. Itis our belief thattheintegrated treat-
ment group wasable toincrease kneeflexion ROMgreater
than theland based group duetothe order ofthe aquatic
component ofthe research. Thewater temperature ofthe
therapeutic poolwas92degrees whichmayhave encour-
aged relaxation, adecrease muscleguarding aroundthesur-
gical joint andincreased jointmovement.23 Thebuoyancy
of water allowed adecrease inbody weight limiting joint
compressive forcespromoting greaterjointmovements and
a symmetrical gaitpattern withlessdiscomfort. Theaquat-
ic environment mayhave acted asagaiting mechanism
resulting inadecrease ofpain andallowing forimproved
pain-free ROMduring exercise. Inaddition, thehydrostatic
pressure ofthe water couldhaveencouraged edemareduc- It
is in the opinion ofthe authors thatthesymptoms cat-
egory ofthe KOOS Indexforthe 6month followupwas
significantly improvedinthe integrated groupsecondary to
the improved kneeflexion ROMthatwasgained byutiliz-
ing the aquatic environment first.Arecent studyhasshown
continued improvements inTotal KneeArthroplasty forup
to 26 weeks aftersurgery. Theincreased ROMgained after
the 6week treatment inthe integrated groupmayhave fa-
cilitated thiscontinued longterm progressY
There havebeen numerous studiesperformed onthe
treatment ofTKA andthis study isnot thefirst study to
investigate theoutcomes ofaquatic therapy compared to
land based therapy. However,moststudies investigating
the outcomes ofaquatic therapy compared withlandhave
been performed onpatients withhipandor kneeinjury
or arthritis andnotnecessarily onTKA.13,14,23,28-32 Acase
study investigating outcomesofapatient withbilateral
TKA including anindependent homeexercise program for
strengthening incombination withskilled physical therapy
in an aquatic environment resultedinincreased ROMand
strength andadecrease inpain andgirth measurements
bilaterally.2 Amore recent studydemonstrated aquatic
therapy tobe beneficial forpatients withOsteoarthritis
(OA) ofthe knee andor hipresulted inreduced painand
joint stiffness aswell asimproved physicalfunction, hip
muscle strength, andquality oflife.13 Unfortunately, those
participating inthe aquatic therapy portion ofthe study
were compared toacontrol groupthatreceived noskilled
physical therapyintervention.
To our knowledge thisisthe first study toinvestigate an
integrated treatmentapproachforTKA duetoOA which
has demonstrated encouragingresults.Hopefully thisstud-
ies result willencourage moretherapists workinginaquatic
physical therapytoperform futureresearch studiesutilizing
an integrated treatmentprotocolforvarious diagnoses.
There areafew limitations ofthis present studythatmay
affect thereproducibility andgeneralizability ofthis inte-
grated treatment approach. Thisstudy usedvarious ex-
ercise equipment bothonland andinthe water thatmay
unavailable toall clinics. Furthermore, duetothe high
cost ofbuilding atherapeutic pool,notallclinics havepool
available tothem. Itispossible toutilize community pools
such asthose inhotels andfitness centers; however the
pools inhotels andfitness centers maynotbeattherapeutic
temperature andmay only beavailable atcertain timesof
the day fortherapy purposes. Theland group subjects in
this study usedlegextension andflexion machines which
again maynotbeavailable inall clinics.

Another component ofthis study effecting generalizability
is the number ofdoctors involved aswell asthe number of
treating therapists andclinics involved. Onlytwodoctors
from asmall orthopedic practicethatperformed theTKA's
for that practice wererecruited forareferral baseforthis
study. Also,thisstudy wasasingle center studyinwhich
treatment wasprovided byone physical therapist andone
physical therapist assistantasneeded. Becauseofthe above
limitations thisstudy wasunable togenerate asubstantial
sample sizetoreach truestatistical significance. Onlythirty
subjects wereabletobe recruited forthis study which in-
fluenced thisstudy tobe apilot study rather thanatrue
randomized clinicaltrial.Having moreclinics involved as
well asmore doctors andtreating therapists inthis research
study mayhave increased oursample sizetoover 100to200
subjects andwould havecontributed tothe reproducibility
and generalizability ofthe study. Also,having thesubjects
return tothe clinic afterthe6month periodformeasure-
ments ofpain, ROM andswelling maygiven usmore infor-
mation ofthe subject's status.
The information fromthispilot study mayprovide abasis
for initiating futurerandomized clinicaltrialstoinvestigate
integrated protocolsforthe treatment ofTKA's.Theseclini-
cal trials should include multiple treatment groupsinvari-
ous orders andshould include: Landtreatment only,Pool
treatment only,PoolthenLand treatment andLand then
Pool treatment. Additionally investigating lowerextremity
strength, balanceandfunction usingmeasurements such
as the Leffs and6minute walktestmay givethefuture re-
searchers moreinsight tothe effectiveness ofperforming
integrated treatmentprotocolsforTKA.
Acknowledgements The author ofthis study would liketothank Rehab 3at
Marshbrook forallowing usetoconduct thisstudy attheir
facility. Iwould alsoliketothank theFoundation forPhysi-
cal Therapy forfunding theresearch withagenerous dona-
tion from theNational Spaand Hot Tub Council. Ithank the
subjects studiedfortheir participation, KellyHebert, DPT,
ATC, CMT forher assistance, Dr.Ernst Linder forstatistical
analysis, Dr.Joshua Cleland forresearch consultation, and
Dr. Robert Harrington andDr.Moby Parsons forreferring
patients forthis study.
1. NIH Consensus StatementonTotal KneeReplacement.
NIH Consens StatesciStatements. 2003Dec8-10; 20(1)
2. Lenkowitz SE,Hasson SM.Aquatic Physical Therapy
and treatment ofpatients withsimultaneous bilateral
total knee arthroplasties. jof Aquatic Physical Therapy.
2003; 11(1):6-13.
3. Enleo LJ,Shields RK.Total hipand knee replacement
treatment programs: Areport usingconsensus. jOspT.
1996;23(1):3-11. 4.
Kennedy D,Stratford P,Pagura S,Walsh m,Woodhouse

Comparison ofGender andGroup Differences in
Self- Report andPhysical Performance MeasuresinTotal
Hip andKnee Arthroplasty Candidates.jof Arthroplasty.
2002; 17(1)70-77.
5. Denis M,Moffet H,Caron F,Ouellet D,Paquet

Effectiveness ofContinuous PassiveMotion and
Conventional PhysicalTherapy AfterTotalKnee
Arthroplasty. PhysicalTherapy. 2006;86(2): 174-185.
6. Kramer J,Speechley M,Bourne R,Rorabeck C,Vaz M.
Comparison ofClinic andHome-Based Rehabilitation
Programs AfterTotalKneeArthroplasty. ClinOrtho and
Related Research. 2003;410:225-234.
7. Ritter M,Campbell E.Effect ofRange ofMotion onthe
Success ofaTotal KneeArthroplasty. jof Arthroplasty.
1987; 2(2):95-97.
8. Spicer D,Curry
Pomeroy D,Badenhausen W,
Schaper L,Suthers K,Smith M.Range ofMotion After
Arthroplastyfor theStiff Osteoarthritic Knee.

Southern OrthoAssoc.2002; 11(4): 227-230.
9. Stevens J,Mizner R,Snyder-Mackler
Electrical Stimulation forQuadriceps Muscle
Strengthening AfterBilateral TotalKneeArthroplasty.
jOspT. 2004:34(1): 21-29.
10. Mizner R,Petterson S,Stevens
Vanderborne K,Snyder-
Early Quadriceps StrengthLossafter Total
Knee Arthroplasty.f ofBone andjoint Surgery. 2005:87-A
(5): 1047-1053.
11. Mizner R,Petterson S,Snyder-Mackler
Strength andtheTime Course ofFunctional Recovery
after Total KneeArthroplasty. jOspT.2005:35(7):
12. Brander VA,Stulberg SD.Rehabilitation followinghip
and knee arthroplasty. PhysMedandRehab ClinofNo

1994; 5(4):815-836.
13. Hinman RS,Heywood SE,Day AR. Aquatic Physical
Therapy forHip andKnee Osteoarthritis: Resultsofa
Single- Blinded Randomized ControlledTrial.PhysTher.
2007; 87(1):32-43.
14. Templeton MS,Booth D,O'Kelly WD.Effects ofaquatic
therapy onjoint flexibility andfunctional abilityin
subjects withrheumatic disease.jOspT. 1996;
15. Bergh
Sjostrom B,Oden A,Sten B.Application of
pain rating scalesingeriatric patients. Department of
Geriatric Medicine, GotborgUniversity, Gotborg
16. Childs JD,Piva SR,Fritz JM.Responsiveness ofthe
numeric painrating scaleinpatients withlowback pain.
Spine. 2005;30(11):1331-1334.

17. Ross M,Worrell TW.Thigh andcalfgirth following
knee injury andsurgery. JOspT.1998;27(1):9-15.
18. Norkin C,White S.Measurement ofjoint motion and
guide togoniometry. FADavis. 1995;140-143.
19. Gogia PP,Braatz JH.Reliability andvalidity of
goniometric measurements ofthe knee. Physical
Therapy. 1987;67(2): 192-195.
20. Roos EM,Toksvig- Larson S.Knee Injury and
Osteoarthritis OutcomeScore(KOOS) -Validation and
Comparison tothe WOMAC inTotal KneeReplace-
ment. Health andQuality ofLife Outcomes. 2003;
1:17 (25May 2003)
21. Kessler S,Lang S,Puhl W,Stove I.The knee injury
and osteoarthritis outcomescores;amulti-functional
questionnaire tomeasure theoutcome inknee
22. Gross- Portney L,Watkins MP.Foundation ofClinical
Research, Application toResearch. PrenticeHall.
23. Wyatt F,Milam S,Manske R,Deere R.The effects of
aquatic andtraditional exerciseprograms onpersons
with knee osteoarthritis.
Strength Conditioning Res.
2001; 15:337-340.
24. Prentice WE,Voight MI.Techniques inMusculoskeletal
Rehabilitation. McGraw-HillProfessional. 2001;
25. Becker BE,Cole AJ.Comprehensive AquaticTherapy.
Boston: Butterworth-Heinemann; 1997.
26. Ruoti RG,Morris DM,ColeAI.Aquatic Rehabilitation.
Philadelphia: Lippincott;1997.
27. Kennedy D,Stratford P,Riddle D,Hanna S,Gollish J.
Assesing Recovery andEstablishing PrognosisFollowing
Total KneeArthroplasty. PhysicalTherapy. 2008;88(1):
28. Kumar PJ,McPherson EJ.Rehabilitation aftertotal knee
arthroplasty. ClinOrtho andRelRes. 1996; 331:93-1 01.
29. Hall J,Skevington M,Maddison P,Chapman K.A
Randomized andControlled TrialofHydrotherapy in
Rheumatoid Arthritis.ArthritisCareandResearch.
1996; 9(3):206-215.
30. Lund H,Weile U,Christensen R,Rostock B,Downey
A, Bartels E,Samsoe B,Bliddal H.JRehabil Med.2008;
40: 137-144.
31. Tovin BJ,Wolf SLetal. Comparison ofthe effects of
exercise inwater andonland onthe rehabilitation of
patients withintra-articular anteriorcruciateligament
reconstruction. PhysTher. 1994; 74:710-19.
32. Sylvester K.Investigation ofthe effects ofhydrotherapy
in the treatment ofosteoarthritic hips.ClinRehabil.
1989;4:223-228. Table
Baseline Demographics ofParticipant Groups
Mean of Meanof
Characteristic ControlGroup IntegratedGroup P-Value
(SD') (SD")
AROM Flexion 93.5(14.7)
AROM Extension 2.1(3.0) 2.4(5.8)
PROM Flexion 99.4(16.0)
PROM Extension 0.80(1.5) 1.27(3.7)
Girth 3"Proximal
46.6(6.0) 47.0(6.1) .87
Girth Mid-Patella 43.9(3.3)
44.5(2.9) .56
Girth 6"Distal
37.0(3.3) 38.0(3.7) .41
KOOS: Pain 63.5(12.0)
43.9(15.8) .01
Symptoms 47.6(10.3)
42.1(131) .21
ADL 68.3(13.6)
55.7(14.7) .02
QOL 38.3(16.5)
Table 2.
Baseline toDischarge6 WeekComparison ofParticipant Groups
Characteristic Mean

between groups
AROM Flexion 1.880
PROM Flexion 1.657
AROM Extension -0.614
PROM Extension
-0.703 .490
Girth 3"Proximal -3.662
Girth MidPatella -2.084
Girth 6"Distal -2.521
Pain -2.707
, Analyzed withtwo-sample Hestnotcorrected forbaseline differences
b Analyzed withANCOVA toaccount fordifferences inbaseline measures

Flow ofparticipants throughthetrial.
Baseline to6Weeks 6Weeks to6Months
Mean P-Value Mean
difference difference
Pain 7.6.3512.0 .30
Symptoms 10.1.49
16.1 .03
ADL 7.0.1211.3
QOL 8.8.1312.3
.40 30
Patients with
unilateral TKA
declined to
participate (n=O)
Manual Therapy
Exercise DescriptionofExercise ExercisePrescription
Recumbent SeatedonRecumbent bike,peddling sothat agentle stretch isfelt.
Total Gym
Withpatient inasemi-supine positiononthe total gymsled,have patient walkfeetforward onthe platform
Squats sothat knees don'tgoover thetoes when squatting. Instructpatienttosquat untilagentle stretch isfelt.
Standing on2nd stepwith feetshoulder widthapartholding ontotherailings withhands. Have Repeat
exercise repetitiously for30seconds
Stair Squats
patientsquatdown keeping heelsdown onthe step, then return tostanding position Repeat
Knee Exten-
Patientproperly set-uponseated nautilus kneeextension machine,instructpatienttoextend both
Repeatexercise repetitiously for30seconds
sion Machine knees,andthen slowly lowerthem. Adjust weight toappropriate levelforeach individual patient.
Hanastring Patient
properly set-uponseated nautilus hamstring curlmachine, instructpa-
Repeatexercise repetitiously for30seconds
tient tobend knees asfar asthey canthen slowly extend backtostarting posi-
Curl Machine
tion.Adjust weight toappropriate levelforeach individual patient. Repeat
Forward Havepatient putone foot flatontop ofa6-8" stepwith theother footflatonthe floor. Instruct
Repeatstep-ups for45seconds.
Step-ups patienttostep upbringing theother footuponto stepthen stepback down withthesame foot.
Lateral Havepatient standwitha6-8" steptothe side ofthem, putone foot flatontop ofthe step. Instruct
Repeatstep-ups for45seconds Repeat2times
Step-ups patienttostep upbringing theother footuponto step. Stepback down withthesame foot.
Single Leg
Instructpatienttostand onone foot (surgical limb)without puttingtheother footdown.
Hold30seconds Repeat6times
Stair Lunge
Instructpatienttoput one foot flatontop ofa12-24" step,lunge for-
Stretch wardbending kneeuntilatolerable stretchisfelt.
Hamstring Havepatient standing withonefoot onthe floor ofthe pool, andtheheel ofthe op-
Stretch on
positefootona12-24" stepkeeping theknee straight. Instructpatienttolean for-
Stairs ward
keeping theback straight untilacomfortable stretchisfelt.
Manual Therapy:
Scar Massage Massage
scarinperpendicular directionandwith moderate pres-
sure sothat thescar andskin ismoving sidetoside.
Medial Patellar
Passivelymovethepatella inthe medial direction.

rior Patellar
Passivelymovethepatella inthe superior direction.

Manual Hana- With
patient insupine position andheel offoot onaV, foam roll,putone hand
string Stretch just
above theknee andtheother handjustbelow theknee. Gently pushkneeto-
ward tableuntilpatient reports agentle stretch isfelt inthe Hamstrings.
Manual Quad-
riceps Stretch
Withpatient inaseated position withboth legsbent hanging overtheside ofthe table, placehands around Complete
Jointmobilizations for10seconds
with Posteriori
PassiveKneeFlexion StretchHoldfor30seconds
Anterior Joint knee
perform repeated PAmobilizations ofthe knee followed byapassive flexionstretchstabilizing femur.

Integrated AquaticExercise Program
Exercise Description
ofExercise Exercise
Shallow Water
Exercises: (Waterdepth


Walking Forward
Instructingpatienttostanding uptall, have patient walkforward withreciprocal armswing. 2Lengths ofthe pool*
Valking Backw'ard Instructingpatienttostanding uptall, have patient walkbackward extending hipwith reciprocal armswing. 2Lengths ofthe pool*
Walking Sideways Have
patient stepping outtothe side with onefoot sothat legsareseparated, instructpatienttosemi-
2Lengths ofthe pool*
with semi-squat squat
keeping heelsdown onthe floor, thenstand backupstepping togetherwithopposite foot.
Clap Under Instruct
patienttowalk fonvard bringing oneknee upas
to march, clapping handsunderthigh. 2Lengths ofthe pool*
Clap Behind Instruct
patienttowalk forward bringing oneheel uptowards buttocks keepingthighverti-
2Lengths ofthe pool*
cal while simultaneously reachingbothhands behind totouch foot.
Straight Leg
Instructpatienttowalk forward kickingonelegout straight infront ofthem. 2
Lengths ofthe pool*
Raise Walk
Stair Lunge Stretch Instruct
patienttoput one foot flatontop ofa12-24" step,lunge fonvard bending kneeuntil atolerable stretchisfelt. Hold30seconds Repeat5times
Stair Squat Instruct
patienttoput both feetshoulder widthapartandflatona12-24" step,squat
Hold10seconds Repeat10times
down holding theside ofthe pool until acomfortable stretchisfelt.
Hamstring Stretch Have
patient standing withonefoot onthe floor ofthe pool, andtheheel ofthe opposite footona12-24" stepkeeping
Hold30seconds Repeat5times
the knee straight. Instructpatienttolean forward keepingtheback straight untilacomfortable stretchisfelt.
Forward Step-up Have
patient putone foot flatontop ofan 8-12" stepwith theother footflatonthe floor. Instruct pa-
Repeat15times Do2sets
tient tostep upbringing theother footuponto stepthen stepback down withthesame foot.
Lateral Step-up Have
patient standwitha8-12" steptothe side ofthem, putone foot flatontop ofthe step. Instruct
Repeat15times Do2sets
patient tostep upbringing theother footuponto step. Stepback down withthesame foot.
Kickboard Have
patient toput akickboard underthesurgical leg'sfoot. Instruct patienttoslowly
Marching raise
thekickboard bendingtheknee towards theirchest asifto march.
Single LegBalance
Havepatient standonone foot (surgical leg).Instruct patienttoholding thesides ofthe kickboard pushingthekickboard Holdbalance onsingle legfor30seconds
with Kickboard
Push andPull perpendicular
intothe water thenpush forward andpull back withthekickboard whilekeeping theirbalance. Repeat2times
Deep Water Exercises:
(Water depth
7' 6")
Heel toButtocks Hanging
verticalinthe water withappropriate flotationdevice,havepa- Repeatfor
tient bring oneheel uptowards buttocks keepingthethigh vertical. 30seconds
Single Knee Hangingverticalinthe water withappropriate flotationdevice,havepatient bend Repeatfor
to Chest one
knee upasifto march keeping theopposite legvertical. 90seconds
Double Knee Hangingverticalinthe water withappropriate flotationdevice,havepatient bend Repeatfor
to Chest both
knees uptoward chestthenreturn tovertical position. 90seconds
Prone Single Withalong barbell undereacharmhave patient gointo prone position onthe water. Keeping backandbuttocks onthe Repeat
Knee toChest surface
ofthe water havepatient bringoneknee uptoward theirchest while keeping theother legstraight outinback. 90seconds
Prone Double With
along barbell undereacharmhave patient gointo prone position onthe water. Keeping back Repeat
Knee toChest andbuttocks onthe surface ofthe water havepatient bringbothknees uptoward theirchest. 90
Bicycling With
patient inavertical position havepatient peddlelegsasifto ride abicycle. Repeat
90 seconds
Land Exercises
Recumbent Bicycle SeatedonRecumbent bike,peddling sothat agentle stretch isfelt. 3minutes
Total GymSquats With
patient inasemi-supine positiononthe total gymsled,have patient walkfeetforward onthe platform Hold30
so that knees don'tgoover thetoes when squatting. Instructpatienttosquat untilagentle stretch isfelt.
Forward Step-ups Have
patient putone foot flatontop ofa6-8" stepwith theother footflatonthe floor. Instruct pa-
Repeatstep-ups for45seconds.
tient tostep upbringing theother footuponto stepthen stepback down withthesame foot.
Lateral Step-ups Have
patient standwitha6-8" steptothe side ofthem, putone foot flatontop ofthe step. Instruct pa-
Repeatstep-ups for45seconds
tient tostep upbringing theother footuponto step. Stepback down withthesame foot.
Single LegBalance Instructpatienttostand onone foot (surgical limb)without puttingtheother footdown. Hold15seconds Repeat6times
Manual Therapy:
Scar Massage Massage
scarinperpendicular directionandwith moderate pressuresothat thescar andskin ismoving sidetoside. 2minutes
Medial Patellar
Passivelymovethepatella inthe medial direction. 1minute
Superior Patellar
Passivelymovethepatella inthe superior direction. 1minute
Manual Hamstring With
patient insupine position andheel offoot ona
foam roll,putone hand justabove theknee andtheother hand
Holdfor30seconds Repeat3times
Stretch just
below theknee. Gently pushkneetoward tableuntilpatient reportsagentle stretch isfelt inthe Hamstrings.
Quadriceps Stretch
Withpatient inaseated position "Withbothlegsbent hanging overtheside ofthe table, placehands around Complete
Jointmobilizations for10
with PosteriorI seconds
PassiveKneeFlexion Stretch
Anterior JointMo- knee
perform repeated PAmobilizations ofthe knee followed byapassive flexionstretchstabilizing femur.
Holdfor30seconds Repeat3times

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