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. 2026 May 20;15:64. doi: 10.1186/s13741-026-00698-x

Influence of proprioceptive enhancement training combined with staged rehabilitation training on knee joint function of patients after total knee arthroplasty

Chao Li 1, Shengkui Xue 1, Qi Shu 1, Hui Wu 1, Le Kang 1,✉
PMCID: PMC13360245  PMID: 42157245

Abstract

Objective

We aimed to evaluate the improvement effect of proprioceptive enhancement training combined with staged rehabilitation training on knee joint function in patients post-total knee arthroplasty (TKA).

Methods

This prospective, randomized controlled trial enrolled 80 patients with knee osteoarthritis after TKA, who were randomly allocated to a control group (routine rehabilitation training, n = 40) or an observation group (proprioceptive enhancement training + staged rehabilitation training, n = 40). Both groups underwent continuous training for 4 weeks, with the intensity tailored to the patients’ tolerance levels. Outcome measures included pain (VAS), knee function (HSS score), balance (BBS), range of motion (MKFA), and daily living ability (ADL). Postoperative complications were recorded.

Results

Both groups showed noticeable post-intervention improvement in all functional measures. After the intervention, the observation group had lower VAS score (Z = -4.448, η² = 0.228, p < 0.001) and ADL score (Z = -2.654, η² = 0.088, p = 0.008), and higher HSS score (t = 3.219, Cohen’s d = 0.720, p = 0.002), BBS score (t = 2.980, Cohen’s d = 0.665, p = 0.004), and MKFA (t = 4.464, Cohen’s d = 0.999, p < 0.001) than the control group. The observation group exhibited a lower incidence of postoperative complications after TKA than the control group (p = 0.048).

Conclusion

Proprioceptive enhancement training & staged rehabilitation training provides superior outcomes in pain relief, functional recovery, and complication reduction post-TKA. This combined approach presents a clinically valuable strategy for optimizing postoperative knee rehabilitation.

Keywords: Knee osteoarthritis, Total knee arthroplasty, Proprioception, Exercise therapy, Kellgren-Lawrence grading scale, Maximum knee flexion angle

Introduction

Knee osteoarthritis (KOA), defined as a chronic degenerative disease, is characterized by main pathological changes including cartilage and subchondral bone degeneration, along with synovitis (Zeng et al. 2021). For KOA, the two major treatment approaches are non-pharmacological treatments and total knee arthroplasty (TKA). Among them, TKA serves as the primary treatment option for patients with severe KOA (Zhang et al. 2024). TKA, a common procedure in orthopaedics, has historically proven successful. By 2040, the number of patients each year undergoing TKA is projected to surpass 1.2 million (Mosher et al. 2024, Shichman et al. 2023). TKA stands as a surgical approach that has repeatedly demonstrated success. It is cost-efficient and highly effective in treating severe KOA. There are three primary fixation methods for TKA, namely cement fixation, cementless fixation, and hybrid fixation (Moya-Angeler et al. 2024). One of the potential complications of TKA is nerve injury, and patients may also experience substantial knee swelling following the surgery (Yau et al. 2022, Cohen and Backstein 2022). Substantial evidence indicates that rehabilitation training after TKA is of great importance. However, maintaining an effective therapeutic outcome remains a challenge (Sardana et al. 2019). Therefore, optimizing the rehabilitation training program after TKA to promote the rapid and comprehensive recovery of patient’s knee joint function has become an urgent issue to be addressed in the current field of rehabilitation medicine.

Studies suggest that for patients who have undergone TKA, incorporating pedaling exercises, weight training, and balance or sensorimotor training into a multidisciplinary program can bring promising benefits following the surgery (Fortier et al. 2021). Additionally, balance training not only reduces the risk of sports injuries and enhances functional performance after injury (Al Attar et al. 2022), but its combination with proprioceptive training and continuous care has also been proven to effectively promote the recovery of knee function after TKA (Lin et al. 2022). However, whether TKA can truly improve proprioception in patients with KOA remains controversial (Xue et al. 2022). Proprioceptive training is a rehabilitation intervention that enhances the brain’s perception of limb position, movement status, and weight-bearing by stimulating mechanoreceptors (such as muscle spindles, Golgi tendon organs, and Ruffini endings) in joints, muscles, and tendons (Valdes et al. 2023). Its core lies in strengthening the input-central integration-motor output pathway of sensory signals to improve posture control and joint stability (Ackerley et al. 2022). In clinical practice, proprioceptive training is often implemented in the forms of angular regression training, balance training, and walking flexibility training. Among them, angular regression training strengthens the memory and feedback regulation ability of knee joint position sense through target angle replication with eyes closed (Ma et al. 2022); balance training utilizes unstable surfaces (such as balance pads) to disrupt static stability, forcing the body to rely on proprioceptive signals for rapid posture adjustment (Rizzato et al. 2024); walking flexibility training improves the integration and utilization efficiency of proprioception in dynamic environments through multi-directional stepping movements and gait retraining (Teran-Wodzinski et al. 2024). Proprioception-based rehabilitation has been proven to be superior to traditional rehabilitation programs in more effectively improving the functional performance of TKA patients (Palanisamy et al. 2024). However, even with postoperative rehabilitation support, existing programs mostly focus on quadriceps strengthening and exercise drills, and muscle weakness and functional limitations persist (Schache et al. 2016). Although progressive resistance training is one of the most commonly used methods after joint replacement surgery, its effectiveness and safety remain controversial (Chen et al. 2021).

Currently, there is a research gap concerning the specific impact of proprioceptive enhancement training combined with staged rehabilitation on knee joint function in patients after TKA. The necessity of this study lies in the current lack of systematic studies to clarify the advantages of this combined training method in reducing complications and improving patients’ quality of life. Moreover, although existing rehabilitation training methods can, to some extent, improve knee joint function in patients after TKA, they often focus on muscle strength training and joint range of motion training (Schache et al. 2016, Chen et al. 2021), while neglecting proprioceptive training. From the perspective of synergistic advantages, by strengthening proprioceptive training, patients’ perception of joint position and movement may be enhanced, thereby improving joint stability. Meanwhile, staged rehabilitation training can gradually adjust the training intensity and difficulty according to the specific recovery situation of patients, ensuring the safety and effectiveness of the training. Therefore, based on the above research gaps and reasons, we aim to clarify the impact of proprioceptive enhancement training combined with staged rehabilitation on knee function in patients after TKA. We hypothesize that proprioceptive enhancement training combined with staged rehabilitation training can alleviate pain, promote functional recovery, improve activities of daily living (ADL), and reduce the risk of complications in patients after TKA.

Materials and methods

Ethnic statement

986 Hospital of Xijing Hospital, Air Force Medical University’s Ethics Committee approved the study. The study subjects offered written informed consent forms.

Research subjects

This study was a prospective, randomized controlled trial. From May 2021 to May 2024, 128 patients with KOA who underwent TKA and were admitted to 986 Hospital of Xijing Hospital, Air Force Medical University were selected. A total of 113 patients were included based on inclusion criteria, and 25 patients were excluded based on exclusion criteria (including 8 with a history of major surgery in the past three years, 1 with hemiplegia, 3 with a history of long-term analgesic treatment, 4 with moderate to severe knee deformities, 2 with infectious diseases, 5 with cardiovascular and cerebrovascular diseases, and 2 with poor compliance). Eight patients refused to participate in the study, and no patients dropped out midway. Ultimately, 80 patients who underwent TKA surgery were included as the study subjects. They were randomly classified into a control group (receiving routine postoperative rehabilitation training, n = 40) and an observation group (receiving proprioceptive enhancement training combined with rehabilitation training, n = 40) (Fig. 1).

Fig. 1.

Fig. 1

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CONSORT 2010 flow diagram

Inclusion criteria: (1) Meeting the diagnostic criteria for KOA; (2) Meeting the surgical indications for TKA (Bemenderfer et al. 2016); (3) Patients undergoing TKA surgery for the first time, with the surgery performed by the same experienced surgical team in our hospital using the same prosthesis (cement-fixed prosthesis) and standard approach (medial parapatellar approach); (4) Unilateral TKA; (5) Kellgren-Lawrence (K-L grading) of KOA patients: Grade III and IV; (6) Aged over 18 years old; (7) All having signed the informed consent form; (8) Having complete clinical data.

Exclusion criteria: (1) Having a history of major surgical treatment in the past 3 years; (2) Patients with myasthenia gravis or Parkinson’s disease; (3) Patients with motor dysfunctions such as hemiplegia; (4) Patients with a long-term history of treatment with analgesic drugs; (5) Patients with cognitive impairment; (6) Body mass index (BMI) > 40 kg/m²; (7) Patients with moderate to severe knee joint deformities; (8) Patients with infectious diseases; (9) Patients with cardiovascular and cerebrovascular diseases; (10) Patients with poor compliance.

Diagnostic criteria for KOA (Zhang et al. 2020): KOA can be diagnosed when criterion ① + any two of criteria ② to ④ are met as follows: ① Recurrent knee joint pain within the recent one month; ② X-ray film shows narrowed joint space, subchondral bone sclerosis, and/or cystic changes, and formation of marginal osteophytes of the joint; ③ No more than 30 min of the duration of morning stiffness; ④ Appearance of crepitus (feeling) during movement.

Sample size calculation

The primary outcome measure of this study was the Hospital for Special Surgery (HSS) knee dysfunction score. Based on the results of a preliminary experiment, the HSS score after intervention was (86.00 ± 7.24) in the observation group and (78.30 ± 8.52) in the control group. Setting the significance level α = 0.05 (two-tailed) and the test power (1-β) = 0.8, the sample size calculation formula for comparing the means of two independent samples was used to calculate n = Inline graphic. Where Z(1−α/2) = 1.96 and Z1−β = 0.84, substituting these values into the formula yielded n ≈ 33. Considering a 20% dropout rate, 40 patients were needed in each group, for a total of 80 patients to be included.

Randomization process and blinding

The researchers numbered the 80 patients in the order of screening and adopted a randomized grouping design. They arbitrarily selected a starting number from the random number table, such as starting from the nth row and mth column, and then read three-digit numbers sequentially to the right as random numbers (each random number corresponding to a patient number). The random numbers were sorted from smallest to largest, and the patients corresponding to the first 40 random numbers were designated as the control group, while those corresponding to the last 40 random numbers were designated as the observation group. The random numbers, group assignments, and other information were written on random cards, which were placed in opaque, sealed envelopes for storage. The generation and storage of random numbers, as well as patient recruitment and grouping, were performed by a third party not involved in this study.

Due to the particularity of the training process, which required close contact between the intervention provider and the patients, blinding was difficult to achieve during the trial. Therefore, the intervention providers were not involved in the outcome assessment to ensure the independence of the intervention providers, outcome assessors, and data analysts. Blinding was applied to the outcome assessors and data analysts in this study.

Rehabilitation methods

Control group: Postoperatively, routine rehabilitation training was carried out. On the day of surgery, patients were instructed to elevate and rest the affected limb. At 24 h postoperatively, ice packs were applied to the affected limb to prevent pressure sores. A continuous passive motion (CPM) device (YTK-E, No. 20162190095, Hangzhou Zhengda Medical Device Co., Ltd., China) was used to conduct knee joint rehabilitation training. The affected limb of the subject was fixed on the joint rehabilitation training device. An appropriate range of motion was set according to the subject’s limb condition, and passive rehabilitation exercises were performed for 20 min per session, twice a day. Patients were guided to perform plantarflexion and dorsiflexion training of the ankle joint three times a day. In the supine position, patients were instructed to straighten their knees and perform isometric contractions of the hamstrings and quadriceps with maximum effort, three times a day. Also in the supine position, patients were instructed to straighten their knees as much as possible and perform straight-leg raise exercises, with 5 repetitions per set and 3 sets per day. The training lasted for 4 weeks.

Observation group: Proprioceptive enhancement training combined with staged rehabilitation training was carried out on the basis of the control group:

  • □ Angular regression training: One week after surgery, subjects were instructed to sit with their lower legs and passively flex their knees to 30° with the assistance of medical staff. After maintaining this position for 5 s, they returned to the initial position. Then, subjects were asked to close their eyes and actively flex their knees, stopping and maintaining the position for 5 s when they subjectively felt they had reached 30°. Medical staff could assist in correcting the angle of active flexion and maintaining it. This process was repeated to complete 3 full knee flexion movements to 30°, followed by 3 full knee flexion movements to 60°. One set consisted of repeating the flexion to 30° and 60° three times each, and subjects performed 5 sets per day.

  • □ Balance training: Two to three weeks after surgery, subjects were instructed to stand with both feet on a balance pad, feet shoulder-width apart, ensuring that the soles of both feet remained on the pad at all times. They actively flexed their knees 15°-30° into a squatting position, maintained it for 30 s, and then returned to the standing position. This was done 10 times a day. Patients were also guided to stand 50 cm away from the balance pad, step forward with the affected limb in a lunge position, place the sole of the foot on the balance pad, maintain body stability, and then retract the lower limb. This was done 5 repetitions per set and 4 sets per day.

  • □ Walking flexibility training: Four weeks after surgery, subjects were instructed to take steps forward, backward, left, and right. During the training, they were told to use the force of the affected knee joint to drive the limb and control the stride to avoid falling. The training lasted for 5 min each time, twice a day. All proprioceptive enhancement training was carried out as long as the patients did not experience limb weakness or numbness. The training lasted for 4 weeks.

The training intensity was tailored to the patients’ tolerance levels.

Observation indicators

Visual Analogue Scale (VAS) scores

The pain conditions of the subjects were evaluated using the VAS before and after the intervention respectively. The VAS is a commonly used pain assessment scale in current clinical practice. A horizontal line (10 cm) was drawn on a piece of paper. One end of the line was marked as 0 mm, representing “completely pain-free”, and the other end was marked as 10 mm, representing “extreme pain”. The pain intensity increased gradually from 0 mm to 10 mm, and the scores ranged from 0 to 10. A higher score indicated a more severe pain level (Sung and Wu 2018). The Cronbach’s α coefficient of the scale is 0.90.

Hospital for special surgery knee scale (HSS) scores

The knee joint function of the subjects was evaluated using the HSS scores before and after the intervention respectively. The HSS knee joint score system was proposed by the Hospital for Special Surgery in the United States in 1976 and is used to assess the function of the knee joint before and after surgery. It includes six aspects with a total score of 100. Excellent: > 85 points, Good: 70–84 points, Moderate: 60–69 points, Poor: < 59 points. A higher score reflects better knee joint function (Feng et al. 2016, McCarthy et al. 2017). The Cronbach’s α coefficient of the scale is 0.89.

Berg balance scale (BBS) scores

The balance of the subjects was evaluated using the BBS before and after the intervention respectively. The BBS is a tool widely used to assess the balance ability of the elderly and rehabilitation patients, mainly for evaluating the patients’ balance ability during standing and walking, as well as predicting the risk of falls. The BBS consists of 13 items, with each item scored from 0 (unable to complete) to 4 (completed normally), and the highest total score is 52 points. A higher score reflects better balance ability. Generally, a score of more than 41 points indicates normal balance function, a score of 40 − 21 points indicates a balance disorder, and a score of less than 20 points indicates a severe balance disorder (Lima et al. 2018). The Cronbach’s α coefficient of the scale is 0.88.

ADL

The ADL ability of the subjects was evaluated using the ADL scale before and after the intervention respectively. The ADL scale was formulated by Lawton and Brody from the United States in 1969, and it is mainly used to estimate the activities of daily living ability of the subjects. Regarding the items and assessment criteria, the ADL scale consists of a total of 14 items, including two parts: one is the Physical Self-Maintenance Scale with a total of 6 items, and the other is the Instrumental ADL Scale with a total of 8 items, using a 1–4 rating scale. The lowest total score of the ADL scale is 14 points, and the highest is 56 points. A lower score indicates higher daily living ability, and a total score ≥ 22 indicates impaired daily living ability (Alsubiheen et al. 2022, Yuenyongviwat et al. 2020). The Cronbach’s α coefficient of the scale is 0.92.

Maximum knee flexion angle (MKFA)

Before and after the intervention, the subjects were instructed to sit, and a goniometer was used to measure the MKFA of the subjects. The larger the angle of the MKFA, the stronger the activity function of the patients’ knee joints (Li et al. 2023).

Postoperative complications

The complications (lower limb venous thrombosis, joint stiffness, pressure sores, swelling) within 1 month after TKA were recorded.

Statistical analysis

Statistical analysis and graphing were implemented with the aid of SPSS 21.0 (SPSS, Inc, Chicago, IL, USA) and GraphPad Prism 9.5 (GraphPad Software Inc) software. Measurement data were tested for normal distribution using the Shapiro-Wilk test. Normally distributed measurement data (such as age, BMI, HSS score, BBS score, and MKFA) were expressed as mean ± standard deviation. Comparisons between the two groups were performed using the independent samples t-test, and comparisons within groups before and after intervention were performed using the paired t-test. Non-normally distributed continuous data (such as disease duration, VAS score, and ADL score) were expressed as median (minimum, maximum). Comparisons between the two groups were performed using the Mann-Whitney U test, and comparisons within groups before and after intervention were performed using the Wilcoxon matched-pairs signed rank test. Categorical variables (such as gender, smoking history, alcohol history, affected side, K-L grade, KOA diagnosis, and postoperative complications) were expressed as number of cases (%), and comparisons were performed using Fisher’s exact test/chi-square test. The p-value was derived from a two-sided test, and when p < 0.05, it signified a statistically significant difference.

Results

Baseline data

The baseline data of the two groups showed no statistically significant differences (p > 0.05), suggesting that the two groups were comparable (Table 1).

Table 1.

Baseline data between the two groups

Index Control group (n = 40) Observation group (n = 40) t/Z P Cohen’d/η2 95% confidence interval (CI)
Age (years) 43.05 ± 7.96 44.88 ± 8.41 0.997 0.322 0.223 -0.216 ~ 0.663
Gender (cases, %) / 0.650 / /
 Male 15 (37.50) 18 (45.00)
 Female 25 (62.50) 22 (55.00)
Smoking history (cases, %) / 0.546 / /
 Yes 5 (12.50) 8 (20.00)
 No 35 (87.50) 32 (80.00)
Drinking history (cases, %) / 0.770 / /
 Yes 8 (20.00) 6 (15.00)
 No 32 (80.00) 34 (85.00)
BMI (kg/m2) 23.44 ± 2.46 24.30 ± 2.96 1.421 0.159 0.316 -0.125 ~ 0.757
Affected side (cases, %) / 0.502 / /
 Left 19 (47.50) 23 (57.50)
 Right 21 (52.50) 17 (42.50)
K-L grading (cases, %) / 0.622 / /
 Ⅲ 27 (67.50) 30 (75.00)
 Ⅳ 13 (32.50) 10 (25.00)
KOA diagnosis (cases, %) / 0.344 / /
 Rheumatoid arthritis 16 (40.00) 11 (27.50)
 Knee osteoarthritis 24 (60.00) 29 (72.50)
 Disease duration (years) 5 (3, 7) 5.5 (2, 9) -1.143 0.253 0.015 /
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The Shapiro-Wilk test was used for the normality test. Measurement data conforming to a normal distribution were expressed as mean ± standard deviation, and an independent samples t-test was used for comparison between the two groups. Measurement data that did not conform to a normal distribution were expressed as the median (minimum value, maximum value), and the Mann-Whitney U test was used for comparison between the two groups. Categorical variables were expressed as the number of cases (%) and analyzed using Fisher’s exact test

BMI Body Mass Index, K-L Kellgren-Lawrence grading scale, KOA Knee Osteoarthritis

Pain levels

After the intervention, the VAS scores of both the control group and the observation group were decreased, and the differences were statistically significant (Z = -5.337, -5.482, η² = 0.356, 0.376, all p < 0.001). Moreover, after the intervention, the VAS score of the observation group was lower than that of the control group, and the difference was statistically significant (Z = -4.448, η² = 0.228, p < 0.001) (Table 2; Fig. 2). This suggests that proprioceptive enhancement training combined with staged rehabilitation training can further alleviate the pain after TKA.

Table 2.

Comparison of pain levels between the two groups before and after the intervention

Control group (n = 40) Observation group (n = 40) Z p
Before the intervention 6 (4,9) 7 (2,9) -0.448 0.654
After the intervention 4 (1,5) 2 (1,4) -4.448 < 0.001
Z -5.337 -5.482
p < 0.001 < 0.001
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The Shapiro-Wilk test was used to test for normal distribution. Non-normally distributed measurement data were expressed as median (minimum, maximum). Comparisons between the two groups were performed using the Mann-Whitney test, and comparisons within groups before and after intervention were performed using the Wilcoxon matched-pairs signed rank test

Fig. 2.

Fig. 2

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Comparison of pain levels between the two groups before and after the intervention. The Shapiro-Wilk test was used for the normality test. Measurement data that did not conform to a normal distribution were expressed as the median (minimum value, maximum value). The Mann-Whitney U test was used for comparison between the two groups, and the Wilcoxon matched-pairs signed rank test was used for comparison within the groups before and after the intervention. ***: P < 0.001; ns: P > 0.05

Knee joint function

Compared with before the intervention, after the intervention, the HSS scores (t = 16.552, 25.943, Cohen’s d (95%CI) = 3.562 (2.857 ~ 4.267), 4.378 (3.557 ~ 5.168), all p < 0.001), BBS scores (t = 28.626, 63.991, Cohen’s d (95%CI) = 6.314 (5.242 ~ 7.386), 5.514 (4.554 ~ 6.475), all p < 0.001), and MKFA (t = 14.377, 39.564, Cohen’s d (95%CI) = 3.125 (2.472 ~ 3.778), 3.677 (2.955 ~ 4.392), all p < 0.001) of both the control group and the observation group were increased, and the differences were statistically significant. After the intervention, the HSS score, BBS score, and MKFA of the observation group were higher than those of the control group, and the differences were statistically significant (t = 3.219, 2.980, 4.464, Cohen’s d (95%CI) = 0.720 (0.268 ~ 1.172), 0.665 (0.215 ~ 1.115), 0.999 (0.530 ~ 1.459), P = 0.002, 0.004, p < 0.001) (Table 3; Fig. 3A-C). This indicates that proprioceptive enhancement training plus staged rehabilitation training can further enhance the functional recovery of the knee joint after TKA.

Table 3.

Comparison of knee function between the two groups before and after intervention

Indicator Time Control group (n = 40) Observation group (n = 40) t p
HSS score (point) Before the intervention 57.98 ± 4.58 59.13 ± 4.85 1.091 0.279
After the intervention 81.68 ± 8.22 87.43 ± 7.75 3.219 0.002
 t 16.552 25.943
 p < 0.001 < 0.001
BBS score (point) Before the intervention 26.83 ± 2.42 27.35 ± 2.77 0.903 0.369
After the intervention 44.53 ± 3.14 47.00 ± 4.21 2.980 0.004
 t 28.626 63.991
 p < 0.001 < 0.001
MKFA (°) Before the intervention 63.55 ± 7.09 64.99 ± 8.18 0.841 0.403
After the intervention 95.52 ± 12.61 109.34 ± 14.97 4.464 < 0.001
 t 14.377 39.564
 p < 0.001 < 0.001
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The Shapiro-Wilk test was used to test for normal distribution. Normally distributed measurement data were expressed as mean ± standard deviation. Comparisons between the two groups were performed using the independent samples t-test, and comparisons within groups before and after intervention were performed using the paired t-test

Fig. 3.

Fig. 3

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Comparison of knee joint functions between the two groups before and after the intervention. A HSS score; B BBS score; C MKFA. The Shapiro-Wilk test was used for the normality test. Measurement data conforming to a normal distribution were expressed as mean ± standard deviation. An independent samples t-test was used for comparison between the two groups, and a paired t-test was used for comparison within the groups before and after the intervention. ***: P < 0.001; **: P < 0.01; ns: P > 0.05

ADL

Compared with before the intervention, after the intervention, the ADL scores of both the control group and the observation group were decreased, and the differences were statistically significant (Z = -3.989, -5.526, η² = 0.199, 0.382, all p < 0.001). Moreover, after the intervention, the ADL score of the observation group was significantly lower than that of the control group, and the difference was statistically significant (Z = -2.654, η² = 0.088, p = 0.008) (Table 4; Fig. 4). This suggests that proprioceptive enhancement training & staged rehabilitation training can further improve the ADL ability after TKA.

Table 4.

Comparison of ADL between the two groups before and after intervention

Control group (n = 40) Observation group (n = 40) Z p
Before the intervention 20 (16,24) 20 (16,26) -0.268 0.789
After the intervention 18 (14,21) 16 (14,19) -2.654 0.008
Z -3.989 -5.526
p < 0.001 < 0.001
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The Shapiro-Wilk test was used to test for normal distribution. Non-normally distributed measurement data were expressed as median (minimum, maximum). Comparisons between the two groups were performed using the Mann-Whitney test, and comparisons within groups before and after intervention were performed using the Wilcoxon matched-pairs signed rank test

Fig. 4.

Fig. 4

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Comparison of the activities of daily living between the two groups before and after the intervention. The Shapiro-Wilk test was used for the normality test. Measurement data that did not conform to a normal distribution were expressed as the median (minimum value, maximum value). The Mann-Whitney U test was used for comparison between the two groups, and the Wilcoxon matched-pairs signed rank test was used for comparison within the groups before and after the intervention. ***: P < 0.001; **: P < 0.01; ns: P > 0.05

Postoperative complications

The incidence of postoperative complications after TKA in the observation group was lower relative to the control group, and the difference was statistically significant (P = 0.048) (Table 5). This indicates that proprioceptive enhancement training plus staged rehabilitation training can effectively diminish the risk of postoperative complications in patients who have undergone TKA surgery.

Table 5.

Postoperative complications between the two groups

Group Lower limb venous thrombosis Joint stiffness Pressure sore Swelling Total incidence of complications (%)
Control group (n = 40) 3 (7.50) 2 (5.00) 1 (2.50) 0 (0.00) 6 (15.00)
Observation group (n = 40) 0 (0.00) 0 (0.00) 0 (0.00) 1 (2.50) 1 (2.50)
P - 0.048
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Categorical variables are expressed as the number of cases (%) and analyzed using Chi-square test

Discussion

TKA has become an effective surgical technique for the treatment of osteoarthritis (Sponer et al. 2022). However, most studies focus on the preoperative and intraoperative stages. In fact, the postoperative recovery is also of great significance. Existing guidelines support qualified clinicians in making a series of treatment decisions to improve quality and efficiency and reduce unnecessary variations in post-TKA care (Jette et al. 2020). This study explored the impact of proprioceptive enhancement training plus staged rehabilitation training on knee joint function of patients after TKA regarding pain levels, knee joint function, ADL, and postoperative complications.

The proprioceptive training protocols typically incorporate exercises focused on agility, balance, coordination, plyometrics, strength perception, and joint repositioning. These exercises are designed to enhance the regulation of joint position sense, kinesthetic awareness, and resistance perception (Clark et al. 2015, Diracoglu et al. 2005). Guo Wei et al.‘s study suggests that active resistance exercise of the lower limbs is beneficial for alleviating pain in TKA patients (Wei et al. 2024). In addition, CPM has a significantly beneficial effect on subjective assessments of pain level, joint stiffness, and functional ability (Richter et al. 2022). This study revealed that after the intervention, the VAS score of the observation group was lower than that of the control group, indicating that proprioceptive enhancement training combined with staged rehabilitation training can more effectively relieve pain in patients after TKA. This is similar to the aforementioned view on pain relief. Mechanistically, proprioceptive enhancement training may stimulate nerve endings around the joint, regulate neural conduction pathways, and reduce the transmission of pain signals. Meanwhile, moderate exercise in staged rehabilitation training can promote the release of endogenous analgesic substances, thus exerting an analgesic effect. However, this mechanism still needs further exploration.

Proprioceptive neuromuscular facilitation therapy makes use of motor and positional stimuli to heighten the neuromuscular response and encourage muscle contraction. It can enhance patients’ pain catastrophizing level and effectively facilitate patients’ knee joint function and BBS score, promoting the improvement of the disease (Lin et al. 2022). Furthermore, maximum strength training after TKA can increase the strength of knee extension muscles (Husby et al. 2018). Quantitative rehabilitation based on enhanced recovery after surgery demonstrates superior clinical utility over traditional rehabilitation approaches by facilitating accelerated knee function recovery, minimizing hospitalization duration, and enhancing patient-reported outcomes (Jiao et al. 2024). Compared with the results of this study, these previous studies did not comprehensively evaluate multiple scores as comprehensively as this study. This study further confirmed that after the intervention, the HSS score, BBS score, and MKFA score of the observation group were higher than those of the control group, indicating that the combined training method improves patients’ knee joint function, balance ability, and overall knee joint functional status. Proprioceptive enhancement training enhances patients’ perception of knee joint position and movement through specific training methods, such as balance training and angle regression training. Staged rehabilitation training gradually increases the training intensity and difficulty according to the patients’ recovery situation, which helps to enhance the strength and coordination of the muscles around the knee joint.

TKA can relieve pain, but muscle strength and function decrease for a long time after surgery (Husby et al. 2018), which may affect the overall quality of life of patients. In addition, the reduced functionality in KOA patients impacts their physical activity levels. Moreover, symptoms like pain, joint limitations, and the decline in functional status among KOA patients lower their quality of life (Gayretli Atan et al. 2025). Previous studies have mostly focused on the impact of symptoms on patients’ quality of life. However, we found that after the intervention, the ADL score of the observation group was lower than that of the control group, reflecting a decrease in the difficulty of patients in performing daily activities and an enhancement of their ADL. This may be because with the improvement of knee joint function, patients have less difficulty in walking, climbing stairs, and other daily activities, and can complete various movements more freely, thus improving their ADL.

Active resistance exercise of the lower limbs may be beneficial for improving the mobility and physical function of patients after TKA by promoting strength recovery and increasing the range of motion of the knee joint (Wei et al. 2024). In addition, preoperative rehabilitation training can shorten the time for patients to get out of bed for the first time after TKA and win the best opportunity for rehabilitation (Zheng et al. 2022). Proprioceptive training can improve proprioception and motor function in a series of healthy and clinical populations (Winter et al. 2022). Proprioceptive training may also have a beneficial effect on knee passive joint position sense, jump function tests, and subjective functional outcomes in patients after anterior cruciate ligament reconstruction (Huang et al. 2025). However, these studies did not involve postoperative complications. Nerve injury is one of the potential complications of TKA. Several studies have shown that patients with osteonecrosis who undergo total hip arthroplasty have a high complication rate (Cohen and Backstein 2022, Karimi et al. 2023). This study shows that the incidence of postoperative complications in the observation group after TKA was lower than that in the control group, indicating that proprioceptive enhancement training combined with staged rehabilitation training helps to reduce the risk of postoperative complications after TKA. Mechanistically, proprioceptive enhancement training and staged rehabilitation training improve the stability of the knee joint, reducing the occurrence of complications such as lower extremity venous thrombosis and joint stiffness. A stable joint can better bear the body’s weight and movement load, thereby reducing the risk of postoperative complications.

In conclusion, the research has confirmed that proprioceptive enhancement training combined with staged rehabilitation training can more effectively relieve postoperative pain after TKA, advance the recovery of knee joint function, improve patients’ ADL, and reduce the risk of postoperative complications. This study combines proprioceptive strengthening training with phased rehabilitation training, providing new ideas and methods for rehabilitation after TKA. Previous studies have mostly focused on a single rehabilitation training method, while this study, through combined training, promotes the recovery of patients’ knee joint function from multiple aspects, including pain relief, improvement of knee joint function, enhancement of ADL, and reduction of complications, achieving significant results. This is the advantage of this study. In addition, clinically, by verifying the effectiveness of proprioceptive strengthening training combined with phased rehabilitation training, it provides a new option for clinicians in treating patients after TKA.

However, this study has the following limitations: First, the study design primarily focuses on statistically significant differences and lacks sufficient assessment of clinical significance, failing to incorporate the minimum clinically important difference (MCID) as a core indicator. Second, the sample size is limited. Third, it does not explore the rehabilitation differences among patients of different age groups after TKA, which may affect the generalizability of the results. Future studies should expand the sample size and conduct multi-center studies to improve the extrapolation of the results. Meanwhile, further analysis can be conducted on the recovery of patients of different age groups after receiving proprioceptive strengthening training combined with phased rehabilitation to provide a basis for developing personalized rehabilitation programs. Additionally, extending the follow-up time and conducting in-depth mechanistic research will help clarify the long-term efficacy and stability of the combined training, providing theoretical support for long-term rehabilitation guidance and the formulation of rehabilitation treatment goals for patients.

Acknowledgements

We would like to give our sincere gratitude to the reviewers for their constructive comments.

Authors’ contributions

Chao Li finished the study design. Shengkui Xue and Qi Shu finished the experimental studies. Hui Wu finished the data analysis. Le Kang finished the manuscript editing. All authors read and approved the final version of the manuscript.

Funding

No funds, grants, or other support was received.

Data availability

The experimental data used to support the findings of this study are available from the corresponding author upon request.

Declarations

Ethics approval and consent to participate

986 Hospital of Xijing Hospital, Air Force Medical Universityl’s Ethics Committee approved the study (approval number: 2020123). The study subjects offered written informed consent forms.

Informed consent was obtained from all individual participants included in the study.

Consent for publication

The participant has consented to the submission of the manuscript to the journal.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The experimental data used to support the findings of this study are available from the corresponding author upon request.

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