Independent home versus supervised rehabilitation following arthroscopic knee surgery--a prospective randomized trial. Efficiency of immediate postoperative inpatient physical therapy following total knee arthroplasty: an RCT Effectiveness of supervised physical therapy in the early period after arthroscopic partial meniscectomy. Physical Therapists’ Use of Therapeutic Exercise for Patients With Clinical Knee Osteoarthritis in the United Kingdom: In Line With Current Recommendations? Physical therapy is effective for patients with osteoarthritis of the knee: a randomized controlled clinical trial. The Effect of Preoperative Exercise on Total Knee Replacement Outcomes Comparison of group-based outpatient physiotherapy with usual care after total knee replacement: a feasibility study for a randomized controlled trial Comparison of Home versus Physical Therapy-Supervised Rehabilitation Programs after Anterior Cruciate Ligament Reconstruction The Effectiveness of Exercise on Recovery and Clinical Outcomes in Patients With Soft Tissue Injuries of the Hip, Thigh, or Knee: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Long-term clinical benefits and costs of an integrated rehabilitation programme compared with outpatient physiotherapy for chronic knee pain. Physiotherapy in osteoarthrosis of the knees. A controlled trial of hospital versus home exercises. Effectiveness of continuous passive motion and conventional physical therapy after total knee arthroplasty: a randomized clinical trial. Effect of adjunctive range-of-motion therapy after primary total knee arthroplasty on the use of health services after hospital discharge. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. A physiotherapist-delivered, combined exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a pilot study. Continuous passive motion versus physical therapy in total knee arthroplasty. Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee
This prospect i ve study compared 30 patients r and omly assigned to either a home exercise program or supervised outpatient physical therapy following arthroscopic partial medial meniscectomy . Their knee functions were assessed at 2 , 4 , and 8 weeks postoperatively using isokinetic analysis and subjective question naires . At each evaluation , the home exercise group performed as well or better than the supervised physical therapy group . There were no statistically significant differences between the two groups . At 4 weeks postoperation , the mean percent deficit in torque ( strength ) between the affected and unaffected limbs was 22.1 % in the supervised rehabilitation group and 22.0 % in the home exercise . The percent deficit in terms of endurance was 7.7 % in the supervised group and 3.6 % in the home group . Similar results were noted with regard to the patients ' subjective evaluations of their knee function and ability to resume work and recreational activities . We conclude that a well-planned , unsupervised home exercise knee rehabilitation program can produce equally good postoperative recovery as compared to a supervised outpatient physical therapy regimen in properly selected patients following arthroscopic partial meniscectomy of the knee Background The main goal of physical therapy treatment ( PT ) in the clinical stage following total knee arthroplasty ( TKA ) is to prepare patients for discharge from the hospital as soon as possible after their operation . Although aggressive rehabilitation is believed to be important , evidence of effects of different exercise programmes following TKA is limited . This led to the question whether the intensity of PT ( once versus twice daily ) following TKA affects short-term recovery , measured as range of motion . Methods A r and omised controlled trial compared an exercise regimen of two sessions per day with a similar programme administered once daily . Primary outcome measure was ROM . Results At the time of hospital discharge , there was no difference between the experimental and control groups in range of motion . Conclusion This study shows that in our setting twice daily PT sessions do not produce different results as daily PT sessions . It may be question ed whether multiple daily therapy sessions are needed as an in-hospital PT regimen in OA total knee patients BACKGROUND AND PURPOSE Controversy exists about the effectiveness of physical therapy after arthroscopic partial meniscectomy . This r and omized controlled trial evaluated the effectiveness of supervised physical therapy with a home program versus a home program alone . SUBJECTS Eighty-four patients ( 86 % males ; overall mean age=39 years , SD=9 , range=21 - 58 ; female mean age=39 years , SD=9 , range=24 - 58 ; male mean age=40 , SD=9 , range=21 - 58 ) who underwent an uncomplicated arthroscopic partial meniscectomy participated . METHODS Subjects were r and omly assigned to either a group who received 6 weeks of supervised physical therapy with a home program or a group who received only a home program . Blinded test sessions were conducted 5 and 50 days after surgery . Outcome measures were : ( 1 ) Hughston Clinic question naire , ( 2 ) Medical Outcomes Study 36-Item Short-Form Health Survey ( SF-36 ) and EuroQol EQ-5D ( EQ-5D ) question naires , ( 3 ) number of days to return to work after surgery divided by the Factor Occupational Rating System score , ( 4 ) kinematic analysis of knee function during level walking and stair use , and ( 5 ) horizontal and vertical hops . RESULTS No differences between groups were found for any of the outcomes measured . DISCUSSION AND CONCLUSION The results indicate that the supervised physical therapy used in this study is not beneficial for patients in the early period after uncomplicated arthroscopic partial meniscectomy Background and Purpose : Physical therapists have an important role in the management of clinical knee osteoarthritis ( OA ) through design ing and supervising exercise programs . This study explored whether their current use of therapeutic exercise for patients with this condition is in line with recent recommendations . Subjects and Methods : A cross-sectional survey was conducted with a r and om sample of chartered ( licensed ) physical therapists ( N=2,000 ) practicing in the United Kingdom . This survey included a vignette describing a patient with clinical knee OA as well as clinical management questions relating to the respondents ’ use of therapeutic exercise . Results : The question naire response rate was 58 % ( n=1,152 ) , with 538 respondents stating they had treated a patient with clinical knee OA in the preceding 6 months . In line with recent recommendations , 99 % of the physical therapists stated they would use therapeutic exercise for this patient population , although strengthening exercises were favored over aerobic exercises . Although nearly all physical therapists would monitor exercise adherence , only 12 % would use an exercise diary . Seventy-six percent of physical therapists would provide up to 5 treatment sessions , and only 34 % would offer physical therapy follow-up after discharge . Discussion and Conclusions : The measure of physical therapists ’ current clinical practice was self-reported clinical behavior on the basis of a vignette . Although this is a valid measure of clinical behavior , in practice , physical therapists may use therapeutic exercise differently . There are disparities between physical therapists ’ current use of therapeutic exercise for clinical knee OA and recent recommendations . Identifying potential ways to overcome these disparities is an important step toward optimizing the outcome from therapeutic exercise for patients with clinical knee OA OBJECTIVE To assess the effectiveness of physical therapy , given either as an individually attended treatment or in a small group format , in terms of pain , physical function , and health related quality of life for patients with osteoarthritis ( OA ) of the knee . METHODS After 2 baseline assessment s , 126 patients were r and omized into one of 3 allocation arms : individual treatments ( n = 43 ) , small group format program ( n = 40 ) , and waiting list control ( n = 43 ) . After re assessment at 8 weeks , patients allocated to waiting list control were r and omized into one of the 2 active treatment arms . Assessment s included both self-report measures ( WOMAC , SF-36 ) and objective measures of physical performance ( gait analysis and muscle strength ) . RESULTS Both physical therapy treatment allocations result ed in significant improvements in pain , physical function , and health related quality of life above the control group ( st and ardized response mean 0.36 to 0.65 ) . Improvements in the self-report measures were substantiated by significant correlated improvements in knee extensor strength and fast walking speed ( rho 0.36 - 0.42 ) . There were no significant differences in effectiveness between the 2 physical therapy allocations for any of the measured outcomes . Improvements gained were maintained for at least 2 months . Responsiveness to treatment was modified by loss of medial joint space width , the interaction being significant for physical function , gait , and knee extensor strength . CONCLUSION Physical therapy , either as an individually delivered treatment or in a small group format , is an effective intervention for patients with knee OA . Responsiveness to this 8 week intervention was modified by loss of medial joint space width This study compared the effects of preoperative physical therapy or general cardiovascular conditioning exercises with the routine procedure of no preoperative physical therapy on patients undergoing primary total knee replacement . Thirty patients were r and omly assigned to 1 of 3 groups . Group 1 was the control group . Group 2 participated in a physical therapy program design ed to strengthen the upper and lower limbs and improve knee range of motion . Group 3 participated in a cardiovascular conditioning program , consisting of arm ergometry , cycle ergometry , aquatic exercises , and aerobic activity . All patients were evaluated preoperatively and postoperatively using the Hospital for Special Surgery Knee Rating , the Arthritis Impact Measurement Scale , and the Quality of Well Being instrument . Both experimental groups tolerated their respective exercise protocol s extremely well . All 3 groups showed significant improvement postoperatively as measured by the Hospital for Special Surgery Knee Rating , the Arthritis Impact Measurement Scale and the Quality of Well Being measurement scales . However , neither type of preoperative exercise added to the degree of improvement after surgery at any of the postoperative evaluations Objective : To evaluate the feasibility of conducting a r and omized controlled trial comparing group-based outpatient physiotherapy with usual care in patients following total knee replacement . Design : A feasibility study for a r and omized controlled trial . Setting : One secondary -care hospital orthopaedic centre , Bristol , UK . Participants : A total of 46 participants undergoing primary total knee replacement . Interventions : The intervention group were offered six group-based exercise sessions after surgery . The usual care group received st and ard postoperative care . Participants were not blinded to group allocation . Outcome measures : Feasibility was assessed by recruitment , reasons for non-participation , attendance , and completion rates of study question naires that included the Lower Extremity Functional Scale and Knee Injury and Osteoarthritis Outcome Score . Results : Recruitment rate was 37 % . Five patients withdrew or were no longer eligible to participate . Intervention attendance was high ( 73 % ) and 84 % of group participants reported they were ‘ very satisfied ’ with the exercises . Return of study question naires at six months was lower in the usual care ( 75 % ) than in the intervention group ( 100 % ) . Mean ( st and ard deviation ) Lower Extremity Functional Scale scores at six months were 45.0 ( 20.8 ) in the usual care and 57.8 ( 15.2 ) in the intervention groups . Conclusion : Recruitment and retention of participants in this feasibility study was good . Group-based physiotherapy was acceptable to participants . Question naire return rates were lower in the usual care group , but might be enhanced by telephone follow-up . The Lower Extremity Functional Scale had high responsiveness and completion rates . Using this outcome measure , 256 participants would be required in a full-scale r and omized controlled trial Background Because of health care funding and policy changes , there is a need to examine the effects of an evolution toward patient-directed ( ie , home-based ) rehabilitation programs on clinical outcomes of patients undergoing anterior cruciate ligament reconstruction . Hypothesis There will be no difference in the effectiveness of a home-based rehabilitation program and a st and ard physical therapy-supervised rehabilitation program in patients 3 months after nonacute anterior cruciate ligament reconstruction with bone-patellar tendon-bone grafts . Study Design R and omized controlled clinical trial ; Level of evidence , 1 . Methods There were 145 patients ( 16 - 59 years ) who attended a presurgery education class . Home-based patients attended 4 physical therapy sessions , and physical therapy-supervised patients attended 17 physical therapy sessions over the first 12 weeks after surgery . All patients followed the same st and ardized rehabilitation program . Study outcome measures included active-assisted knee flexion and passive knee extension range of motion , knee range of motion during walking , KT computerized arthrometer results , and isokinetic quadriceps and hamstrings strength . Patient outcomes were dichotomized as either clinical ly acceptable or unacceptable . Rehabilitation programs were compared by the proportion of acceptable patients in each group . Results The home-based group had a significantly higher percentage of patients with acceptable flexion and extension range of motion compared to the st and ard physical therapy group ( flexion , 67 % vs 47 % ; extension , 97 % vs 83 % ) . There were no significant differences between the groups in range of motion during walking , ligament laxity , and strength . Conclusion A structured , minimally supervised rehabilitation program was more effective in achieving acceptable knee range of motion in the first 3 months after anterior cruciate ligament reconstruction than a st and ard physical therapy-based program . Clinical Relevance Recreational athletes undergoing nonacute anterior cruciate ligament reconstruction can successfully reach acceptable rehabilitation goals in the first 3 months after surgery with a limited number of purpose ful physical therapy education sessions , allowing recreational athletes more flexibility when integrating the necessary postoperative rehabilitation into their daily activities OBJECTIVE The purpose of this systematic review was to determine the effectiveness of exercise for the management of soft tissue injuries of the hip , thigh , and knee . METHODS We conducted a systematic review and search ed MEDLINE , EMBASE , PsycINFO , the Cochrane Central Register of Controlled Trials , and CINAHL Plus with Full Text from January 1 , 1990 , to April 8 , 2015 , for r and omized controlled trials ( RCTs ) , cohort studies , and case-control studies evaluating the effect of exercise on pain intensity , self-rated recovery , functional recovery , health-related quality of life , psychological outcomes , and adverse events . R and om pairs of independent review ers screened titles and abstract s and assessed risk of bias using the Scottish Intercollegiate Guidelines Network criteria . Best evidence synthesis methodology was used . RESULTS We screened 9494 citations . Eight RCTs were critically appraised , and 3 had low risk of bias and were included in our synthesis . One RCT found statistically significant improvements in pain and function favoring clinic-based progressive combined exercises over a " wait and see " approach for patellofemoral pain syndrome . A second RCT suggests that supervised closed kinetic chain exercises may lead to greater symptom improvement than open chain exercises for patellofemoral pain syndrome . One RCT suggests that clinic-based group exercises may be more effective than multimodal physiotherapy in male athletes with persistent groin pain . CONCLUSION We found limited high- quality evidence to support the use of exercise for the management of soft tissue injuries of the lower extremity . The evidence suggests that clinic-based exercise programs may benefit patients with patellofemoral pain syndrome and persistent groin pain . Further high- quality research is needed BACKGROUND Chronic knee pain is a major cause of disability in the elderly . Management guidelines recommend exercise and self-management interventions as effective treatments . The authors previously described a rehabilitation programme integrating exercise and self-management [ Enabling Self-management and Coping with Arthritic knee Pain through Exercise ( ESCAPE-knee pain ) ] that produced short-term improvements in pain and physical function , but sustaining these improvements is difficult . Moreover , the programme is untried in clinical environments , where it would ultimately be delivered . OBJECTIVES To establish the feasibility of ESCAPE-knee pain and compare its clinical effectiveness and costs with outpatient physiotherapy . DESIGN Pragmatic , r and omised controlled trial . SETTING Outpatient physiotherapy department and community centre . PARTICIPANTS Sixty-four people with chronic knee pain . INTERVENTIONS Outpatient physiotherapy compared with ESCAPE-knee pain . OUTCOMES The primary outcome was physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index . Secondary outcomes included pain , objective functional performance , anxiety , depression , exercise-related health beliefs and healthcare utilisation . All outcomes were assessed at baseline and 12 months after completing the interventions ( primary endpoint ) . ANCOVA investigated between-group differences . RESULTS Both groups demonstrated similar improvements in clinical outcomes . Outpatient physiotherapy cost pound 130 per person and the healthcare utilisation costs of participants over 1 year were pound 583 . The ESCAPE-knee pain  programme cost pound 64 per person and the healthcare utilisation costs of participants over 1 year were pound 320 . CONCLUSIONS ESCAPE-knee pain can be delivered as a community-based integrated rehabilitation programme for people with chronic knee pain . Both ESCAPE-knee pain and outpatient physiotherapy produced sustained physical and psychosocial benefits , but ESCAPE-knee pain cost less and was more cost-effective Patients with osteoarthrosis of the knee were taught two simple exercises to be practised daily with graduated weights , recording the details in an instruction/record book . Patients were r and omly divided into those receiving treatment ( and short-wave diathermy ) at hospital ( group A ) , and those doing their exercises at home ( group B ) . Both groups showed decreased pain and increased function , maximum weight lift and endurance at the end of 4 weeks . There was no difference between the groups . Benefit was retained by most of those patients notified at 6 weeks of a further assessment session at 12 weeks ; most of these subjects continued daily exercises , whereas those not notified in advance were more likely to cease exercising and experience more pain . The exercise regimens are easy to perform and document . It is suggested that if such regimens were routinely used there would be great practical benefits for patient and physiotherapist BACKGROUND AND PURPOSE This r and omized clinical trial was conducted to compare the effectiveness of 3 in-hospital rehabilitation programs with and without continuous passive motion ( CPM ) for range of motion ( ROM ) in knee flexion and knee extension , functional ability , and length of stay after primary total knee arthroplasty ( TKA ) . SUBJECTS Eighty-one subjects who underwent TKA for a diagnosis of osteoarthritis were recruited . METHODS All subjects were r and omly assigned to 1 of 3 groups immediately after TKA : a control group , which received conventional physical therapy intervention only ; experimental group 1 , which received conventional physical therapy and 35 minutes of CPM applications daily ; and experimental group 2 , which received conventional physical therapy and 2 hours of CPM applications daily . All subjects were evaluated once before TKA and at discharge . The primary outcome measure was active ROM in knee flexion at discharge . Active ROM in knee extension , Timed " Up & Go " Test results , Western Ontario and McMaster Universities Osteoarthritis Index question naire scores , and length of stay were the secondary outcome measures . RESULTS The characteristics of and outcome measurements for the subjects in the 3 groups were similar at baseline . No significant difference among the 3 groups was demonstrated in primary or secondary outcomes at discharge . DISCUSSION AND CONCLUSION The results of this study do not support the addition of CPM applications to conventional physical therapy in rehabilitation programs after primary TKA , as applied in this clinical trial , because they did not further reduce knee impairments or disability or reduce the length of the hospital stay INTRODUCTION There is controversy as to whether continuous passive motion ( CPM ) after total knee arthroplasty ( TKA ) , which is the st and ard treatment , confers significant benefit with respect to outcome . The primary purpose of this study was to determine if CPM or slider-board ( SB ) therapy , used as adjuncts to st and ardized exercises ( SEs ) during the acute-care hospital stay , result ed in a reduced total length of hospitalization and post-discharge rehabilitation in patients who underwent primary TKA . METHODS We carried out a r and omized , clinical trial on 120 patients who received a TKA at the University of Alberta Hospital , Edmonton , a tertiary care institution . The study horizon began at the point of discharge from the hospital and continued up to 6 months after operation . Postoperatively , patients ( 40 in each group ) received CPM and SEs , SB therapy and SEs or SEs alone while in the tertiary Health service use was compared using transfer institution length of stay(LOS ) , post-discharge rehabilitation , readmission and complication rates and their associated costs . RESULTS There were no differences in health service use or costs among the 3 groups over the 6-month study . The rates of postoperative complications and readmissions also were similar among the groups . Increased health service use associated with knee flexion that was less than 60 degrees at discharge , but similar proportions of patients with poor knee range of movement ( ROM ) at discharge were found in each group . CONCLUSIONS This finding suggests that adjunctive ROM therapy , as used in this study , does not reduce health service use . Further research is required to determine if adjunctive ROM therapy after discharge from the surgical hospital decreases health service utilization in those patients who have poor knee ROM at the time of discharge BACKGROUND AND PURPOSE Manual therapy and exercise have not previously been compared with a home exercise program for patients with osteoarthritis ( OA ) of the knee . The purpose of this study was to compare outcomes between a home-based physical therapy program and a clinical ly based physical therapy program . SUBJECTS One hundred thirty-four subjects with OA of the knee were r and omly assigned to a  clinic treatment group ( n=66 ; 61 % female , 39 % male ; mean age [+/-SD]=64+/-10 years ) or a home exercise group ( n=68 , 71 % female , 29 % male ; mean age [+/-SD]=62+/-9 years ) . METHODS Subjects in the clinic treatment group received supervised exercise , individualized manual therapy , and a home exercise program over a 4-week period . Subjects in the home exercise group received the same home exercise program initially , reinforced at a clinic visit 2 weeks later . Measured outcomes were the distance walked in 6 minutes and the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) . RESULTS Both groups showed clinical ly and statistically significant improvements in 6-minute walk distances and WOMAC scores at 4 weeks ; improvements were still evident in both groups at 8 weeks . By 4 weeks , WOMAC scores had improved by 52 % in the clinic treatment group and by 26 % in the home exercise group . Average 6-minute walk distances had improved about 10 % in both groups . At 1 year , both groups were substantially and about equally improved over baseline measurements . Subjects in the clinic treatment group were less likely to be taking medications for their arthritis and were more satisfied with the overall outcome of their rehabilitative treatment compared with subjects in the home exercise group . DISCUSSION AND CONCLUSION Although both groups improved by 1 month , subjects in the clinic treatment group achieved about twice as much improvement in WOMAC scores than subjects who performed similar unsupervised exercises at home . Equivalent maintenance of improvements at 1 year was presumably due to both groups continuing the identical home exercise program . The results indicate that a home exercise program for patients with OA of the knee provides important benefit . Adding a small number of additional clinical visits for the application of manual therapy and supervised exercise adds greater symptomatic relief BACKGROUND Osteoarthritis ( OA ) of the knee is associated with a number of physical and psychological impairments . Unfortunately , very few treatment strategies are capable of addressing both types of impairments concurrently . We performed a pilot , r and omized controlled , proof of principle trial investigating the feasibility and effects of an intervention combining physical exercise and pain coping skills training ( PCST ) . METHODS Twenty patients with a clinical and radiographical diagnosis of tibiofemoral OA were r and omized to receive either 10 weeks of physiotherapist supervised exercises ( lower limb strengthening and walking ) combined with non-directive counseling ( NDC ) or the same exercise program delivered concurrently with PCST . Primary outcomes included self-reported pain and pain coping , while secondary outcomes included self efficacy and self-reported physical function . RESULTS Ten participants were r and omized to each group and both groups exhibited significant improvements in isometric knee strength , self-reported knee pain and physical function , self efficacy for control of pain management and other arthritis symptoms . Only those in the exercise + PCST group reported statistically significant improvements in pain control coping and rational thinking . No between-group differences existed in any outcome ( 0.07 < p < 0.98 ) . Based on our findings , 63 participants per group would be needed for future large-scale studies using similar outcome measures and design . CONCLUSIONS Our study showed that an intervention that combines exercise and PCST within the same treatment session and delivered by specially-trained physiotherapists is feasible and can improve both physical and psychological outcomes in individuals with knee OA . LEVEL OF EVIDENCE Level II Clinical Trials Registry number : ACTRN12609000623291 To determine the justification of a continuous passive motion machine in the treatment of postoperative total knee arthroplasties , a comparative study of 50 consecutive patients with simultaneous bilateral total knee arthroplasties was undertaken . The patients served as their own controls because one r and omly selected knee was placed in the machine while the remaining knee was treated with physical therapy only . There was no significant difference in the range of motion during the eight days of hospitalization or the follow-up visits at two weeks , two months , six months , and one year . There was a significant decrease in the swelling about the knee . The continuous passive motion treated knees appeared to be generally weaker as revealed by more extensor lags and flexor tightness at discharge from the hospital . Also , increased costs incurred from the need for additional equipment and increased staff time made the machine neither cost-effective nor beneficial Arthritis has been identified as the most common cause of disability in the United States ( 1 , 2 ) . Thirty-three percent of persons 63 to 94 years of age are affected by osteoarthritis of the knee , which often limits the ability to rise from a chair , st and comfortably , walk , and use stairs ( 3 , 4 ) . Acetaminophen and nonsteroidal anti-inflammatory drugs ( NSAIDs ) are commonly used to treat osteoarthritis . Use of NSAIDs can lead to gastric complications , increased risk for hospitalization , and death ( 5 ) . Other treatment options for persons with osteoarthritis of the knee include physical therapy exercise and treatment programs , cortisone injections , and joint replacement surgery . Puett and Griffin ( 6 ) review ed 15 controlled trials of nonmedicinal , noninvasive therapies for hip and knee osteoarthritis from 1966 through 1993 ( 6 ) . The authors concluded that exercise reduces pain and improves function in patients with osteoarthritis of the knee , but the optimal exercise regimen has not been determined . Fitness walking , aerobic exercise , and strength training have all been reported to result in functional improvement in patients with osteoarthritis of the knee ( 6 - 12 ) . Unweighted treadmill walking has not been shown to decrease pain associated with osteoarthritis of the knee ( 13 ) . Other research ers ( 14 , 15 ) have concluded that exercise may benefit patients with osteoarthritis but advise that long-term studies are required to determine the appropriate amounts of exercise to avoid accelerating the underlying process of arthritis . Active and passive range-of-motion exercise is considered an important part of rehabilitation programs for patients with osteoarthritis ( 16 - 18 ) . Physical therapists frequently use manual therapy procedures as part of comprehensive rehabilitation programs to help patients regain joint mobility and function ( 19 ) . We evaluated the effectiveness of manual physical therapy for osteoarthritis of the knee , as applied by physical therapists with formal training in such an approach ( 20 ) . Our hypothesis was that physical therapy consisting of manual therapy to the knee , hip , ankle , and lumbar spine combined with range-of-motion , strengthening , and cardiovascular exercises would be more effective than placebo for improving function , decreasing pain and stiffness , and increasing the distance walked in 6 minutes . Methods Patients Eighty-three patients with osteoarthritis of the knee were r and omly assigned to receive treatment ( n=42 ; 15 men and 27 women [ mean age , 60 11 years ] ) or placebo ( n=41 ; 19 men and 22 women [ mean age , 62 10 years ] ) . All patients were referred by physicians to physical therapy for osteoarthritis of the knee . Physicians at the various clinics in the medical center who normally see patients with osteoarthritis of the knee were informed of the study so that appropriate referrals could be made . If the patients met our inclusion criteria , they were offered the opportunity to participate . The main inclusion criterion was a diagnosis of osteoarthritis of the knee based on fulfillment of one of the following clinical criteria developed by Altman and colleagues [ 21 ] : 1 ) knee pain , age 38 years or younger , and bony enlargement ; 2 ) knee pain , age 39 years or older , morning stiffness for more than 30 minutes , and bony enlargement ; 3 ) knee pain , crepitus on active motion , morning stiffness for more than 30 minutes , and bony enlargement ; or 4 ) knee pain , crepitus on active motion , morning stiffness for more than 30 minutes , and age 38 years or older . Altman and colleagues found this criteria to be 89 % sensitive and 88 % specific ( 21 - 23 ) . Patients were required to be eligible for military health care , have had no surgical procedure on either lower extremity in the past 6 months , and have no physical impairment unrelated to the knee that would prevent safe participation in a timed 6-minute walk test or any other aspect of the study . Patients had to have sufficient English- language skills to comprehend all explanations and to complete the assessment tools . They were also required to live within a 1-hour drive of the physical therapy clinic . Patients who could not attend the required number of visits or had received a cortisone injection to the knee joint within the previous 30 days were not enrolled . Patients were instructed to keep taking any current medications and not to start taking new medications for osteoarthritis during the clinical treatment and 8-week follow-up . Therapy with any osteoarthritis medication must have been initiated at least 30 days before participation in the study . The study was approved by the institutional review board of Brooke Army Medical Center , Fort Sam Houston , Texas . All patients completed an informed consent form and were advised of the risks of the study , including increased symptoms , injuries from falls , and cardiovascular events . No external funding was received for this study . Procedure Patients who met the inclusion criteria were r and omly assigned to one of two groups . Blank folders were numbered from 1 to 100 and were given concealed codes for the group of assignment , determined by a r and om-number generator . When a patient was eligible and gave consent to participate , the treating therapist drew the next folder from the file , which determined the group of assignment . The treatment group received a combination of manual physical therapy and supervised exercise . The placebo group received ultrasound at a subtherapeutic intensity . Neither group was aware of the treatment that the other group was receiving . Demographic data collected for each patient included age , sex , occupation , height , weight , duration of symptoms , presence of symptoms in one or both knees , previous knee surgery , medications , and present activity level . Knee radiographs were obtained and read by a radiologist who assigned a radiographic severity rating for osteoarthritis ( 24 ) . Dependent variables measured in this study were the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) score ( 25 ) and distance covered during a timed 6-minute walk test . The WOMAC Osteoarthritis Index consists of 24 questions , each corresponding to a visual analogue scale . This test has been shown to be a reliable , valid , and responsive multidimensional outcome measure for evaluation of patients with osteoarthritis of the hip or knee ( 26 ) . The timed 6-minute walk test measures the distance a patient walks in 6 minutes and has been demonstrated to be a reliable measurement of functional exercise capacity ( 27 ) . All measurements of dependent variables were obtained by a trained research assistant who was blinded to group assignment . After research assistants obtained pretreatment values for the dependent variables , patients returned to the treating physical therapist for thorough st and ardized clinical examination of the knee , hip , ankle , and lumbar spine . Treatment was initiated according to group assignment . The treatment group received manual physical therapy as indicated by the results of the examination . The manual therapy treatment techniques , consisting of passive physiologic and accessory joint movements , muscle stretching , and soft-tissue mobilization , were applied primarily to the knee . The same treatments were also administered to the lumbar spine , hip , or ankle if these areas showed limitation in active or passive movement , were symptomatic , or were contributing to overall lower limb dysfunction ( 28 - 31 ) . A minimal pain level was not exceeded in any treatment . The treatment group also performed a closely supervised st and ardized knee exercise program at each of the eight treatment sessions . This program consisted of active range-of-motion exercises for the knee , muscle strengthening exercises for the hip and knee , muscle stretching for the lower limbs , and riding a stationary bike . All of the activities were mutually reinforcing , with repeated gentle challenges to the end ranges of movement . An outline of the exercise program is shown in the Appendix Figure . The physical therapist increased the number of strengthening exercise bouts and the stationary bike riding time on the basis of patient tolerance . The current literature provides efficient methods to produce the desired effects of increasing strength , flexibility , and range of motion ( 32 - 35 ) . At each session , the physical therapist examined the patient for adverse signs and symptoms , such as increased pain , joint effusion , and increased skin temperature over knee joints . These signs and symptoms of osteoarthritis had to be stable or decreasing before manual therapy or exercise was progressed . Patients exercised in a painless or minimally painful manner . If any post-treatment or exercise soreness lasted more than a few hours , the regimen was decreased accordingly for that patient . The placebo group received treatment by the physical therapist that consisted of subtherapeutic ultrasound for 10 minutes at an intensity of 0.1 W/cm2 and 10 % pulsed mode ( lowest setting and greatest cycle interruption ) to the area of knee symptoms . The placebo group received the same subjective and h and s-on objective reevaluation before and after each session as the treatment group . The amount of time directly spent with the treating therapist was approximately 30 minutes for both groups . The treatment group required an additional 30 to 45 minutes to perform their exercises in the clinic . Both groups were treated twice weekly for 4 weeks , for a total of eight clinic treatments . Patients in the treatment group also performed the same exercises at home , except for the closed-chain strengthening exercises , on the days on which they were not treated in the physical therapy clinic . They also walked at home each day at a comfortable pace and distance . The treating physical therapist instructed each patient in the performance of the exercises and provided a detailed h and out containing instructions and photographs of the exercises . Each patient maintained a home exercise
In select young and healthy population with few co morbidities  supervised physical therapy  is no more beneficial than a  home exercise program  following relatively simple knee surgical procedures ( arthroscopic meniscetomy ) .
Physical therapy is common following a knee surgery .
With rising healthcare costs there is debate as to the appropriateness of outpatient physical therapy following such interventions .
Many of the existing controlled trials have concluded that there is no benefit to subjects that receive supervised physical therapy when compared to subjects that perform their exercises at home .
The purpose of this systematic review was to consider the existing evidence regarding benefit following  knee surgery  and evaluate the quality , internal and external validity of such evidence .