Clinical practice guideline for physical therapist management of total knee arthroplasty: revision 2026

Abstract

An updated clinical practice guideline on total knee arthroplasty, initially published in 2020, was developed by an American Physical Therapy Association volunteer guideline development group consisting of physical therapists, an orthopedic surgeon, and an occupational therapist. The guideline was based on a systematic review of current scientific literature. Twenty recommendations were formulated. Benefits, harms, feasibility, and role of patient preferences in implementing these recommendations were identified. Recommendations identified current gaps in knowledge and future areas of needed research.

Introduction

Overview

This clinical practice guideline (CPG) is based on a systematic review of published studies with regard to the physical therapist management of patients undergoing total knee arthroplasty (TKA). In addition to providing practice recommendations, this guideline also highlights limitations in the literature and areas that require future research. This guideline is intended to be used by all qualified and appropriately trained physical therapists involved in the management of patients undergoing TKA. It is also intended to serve as an information resource for decision-makers and developers of practice guidelines and recommendations.

Goals and rationale

Current evidence-based medicine standards demand that clinicians use the best available evidence in their clinical decision-making, incorporate clinical expertise, and consider the patient’s values. To assist clinicians, this guideline contains a systematic review of the available literature regarding the management of patients undergoing TKA. The systematic review detailed herein was conducted on studies published between 1995 and 2024 and demonstrates areas where additional research is needed to improve the management of patients undergoing TKA.

The primary goal of this CPG is to improve patient outcomes after TKA. Studies have suggested the presence of excessive variation in post-TKA rehabilitation care and potential underdosing of therapeutic interventions in this population.^1,2 Guideline implementation may help to reduce unwarranted variation in care and improve uptake of best-evidence interventions. Recent evidence suggests that a majority of physical therapists are aware of CPGs but that some experience barriers to their routine implementation, such as overly lengthy CPGs and heavy workloads. Within the TKA population, evidence suggests that following clinical guidelines is associated with both improved patient-reported functional outcomes and reduced variation in rehabilitation care.^3–6

Intended users

This guideline is intended to be used by physical therapists for the management of patients who will undergo or have undergone TKA. Orthopedic surgeons, adult primary care clinicians, geriatricians, hospital-based adult medicine specialists, physiatrists, occupational therapists, nurse practitioners, physician assistants, emergency clinicians, and other health care professionals who routinely see this type of patient in various practice settings may also benefit from this guideline. Some of those professionals also have their own CPGs, such as the American Academy of Orthopaedic Surgeons’ (AAOS) Surgical Management of Osteoarthritis of the Knee: Evidence-Based Clinical Practice Guideline.⁷ This American Physical Therapy Association (APTA) guideline is not intended for use as a benefits determination document.

Patient population

This guideline addresses the pre- and postoperative management of adult patients who have knee osteoarthritis and are undergoing primary TKA. It is not intended to address management of revision or partial knee arthroplasty, pediatric patients, or patients undergoing TKA for reasons other than osteoarthritis. In addition, this guideline is not intended to address nonoperative management of patients with osteoarthritis.

Burden of disease

Knee osteoarthritis is a leading cause of musculoskeletal disability in the United States and worldwide. Global prevalence of osteoarthritis is 7.6%, and incidence is rising, especially in adults with early onset of osteoarthritis before age 55. The societal burden of osteoarthritis is high, with Years Lived with Disability due to osteoarthritis doubling from 1990 to 2019.⁸

End-stage knee osteoarthritis often leads to TKA, which is one of the most commonly performed orthopedic surgeries in the lower extremity. In 2019, 480,958 TKAs were performed on patients with Medicare in the United States; current estimates for total annual TKAs in the United States are nearly 800,000.⁹ Since 2000, the annual volume of TKAs increased by 156%, and projections indicate a continued growth rate of 4.44% per year over the next few decades, reaching nearly 3 million surgeries per year by 2060.¹⁰

Surgical techniques for TKA continue to change over time, which also affects rehabilitation settings and protocols. Continued development of improved surgical techniques also relates to the trend of patients receiving TKA having shorter hospital lengths of stay and more frequent discharge directly to home with no inpatient admission.¹¹

Risk factors

Both treatable or modifiable risk factors and nonmodifiable risk factors will impact outcomes after TKA. An understanding and appreciation of the risk factors helps inform care and determine prognosis. The guideline development group (GDG; also “work group”) (Figure 1) identified aspects of the relationship between risk factors and outcomes in this patient population. Due to the volume of information regarding risk factors for TKA and certain outcomes after TKA, this information is available as a supplement to this clinical practice guideline (Suppl. Material 1).

Figure 1.

Guideline Development Group.

Potential benefits, risks, harms, and costs

The potential benefits, risks, harms, and costs are provided for each recommendation within this document.

Future research

Consideration for future research is provided for each recommendation within this document.

Methods

The methods used to create this CPG were intended to minimize bias and enhance transparency in the selection, appraisal, and analysis of the available evidence. These processes are vital to the development of reliable, transparent, and accurate clinical recommendations for management of patients undergoing TKA. Methods from the APTA Clinical Practice Guideline Process Manual¹² and AAOS Clinical Practice Guideline Methodology¹³ were used in the development of this CPG. Since this last edition, AAOS has updated its study appraisal methodology to ensure concordance with the Cochrane handbook¹⁴ and the Risk Of Bias In Non-randomized Studies,¹⁵ Quality Assessment of Diagnostic Accuracy Studies,¹⁶ and Quality in Prognosis Studies¹⁷ tools as applicable (full methodology can be found on the AAOS website). Additionally, to align with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, all observational studies are now assigned a base appraisal of low-quality evidence.

GDG team

APTA sought out the expertise of the AAOS Evidence-Based Medicine Unit as paid consultants to assist in the creation of this CPG. APTA put out a call for GDG applicants in July 2023. APTA staff selected a balanced team of volunteer member physical therapists: clinicians, educators, researchers, and an administrator (M.B., A.B., L.C., P.D., C.H., J.T., D.S.). APTA then requested organizational representatives from AAOS, American Occupational Therapy Association, and National Association of Orthopaedic Nurses to complete the work group: orthopedic surgeon (P.M.), occupational therapist (K.L.), and total joint replacement program coordinator (S.C.). A patient was included during the formulation of the 2020 CPG¹⁸ as well as a part of the peer-review process but not as a part of the GDG.

Process

This CPG was prepared by the GDG with the assistance of APTA staff and the AAOS Clinical Quality and Value Department (staff evidence-based medicine methodologists). To develop this guideline, the GDG held an introductory meeting on November 5, 2023, to establish the scope of the CPG. Previous PICO(T) (population, intervention, comparison, outcome, and time) questions were reviewed and edited on the basis of feedback from the GDG. New PICO(T) questions were also nominated. All questions were approved by the GDG prior to conducting the literature search.

Literature searches

The medical librarian from AAOS created and executed the searches. Suppl. Material 2 contains the search strategies used. The medical librarian conducted a comprehensive search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials using key terms and concepts from the PICO(T) questions. Retrospective noncomparative case series, medical records review, meeting abstracts, meta-analyses, systematic reviews, historical articles, editorials, letters, and commentaries were excluded. Bibliographies of relevant systematic reviews were hand searched for additional references. All databases were last searched on January 2, 2025, and limited to publications in English. Searches were limited to publication dates from 1995 to 2025 for new PICO(T) questions or if PICO(T) questions from the 2020 CPG were edited to maintain consistency with the 2020 CPG. For retained PICO(T) questions, the search date was limited from July 13, 2018 (prior search end date of the 2020 CPG), to January 2, 2025.

Best-evidence synthesis

The evidence-based medicine methodologists identified the studies that met inclusion criteria predetermined by the GDG. The flow chart of prospective and included studies is shown in Figure 2, and the list of studies not meeting inclusion criteria is available in Suppl. Material 3. The methodologists also performed quality assessments of each included study (Table 1). The guideline includes only the best available evidence for any given outcome addressing a recommendation. Accordingly, the highest-quality evidence for any given outcome is included first, if it was available. In the absence of 2 or more occurrences of an outcome based on the highest-quality evidence, outcomes based on the next level of quality were considered until at least 2 or more occurrences of an outcome had been acquired. For example, if there were 2 “moderate”-quality occurrences of an outcome that addressed a recommendation, the recommendation did not include “low”-quality occurrences of evidence for this outcome. A summary of excluded articles can be viewed in Suppl. Material 3, and the data findings for each recommendation can be viewed in Suppl. Material 4.

Figure 2.

Study Attrition Flowchart.

Table 1.

Rating of quality of evidence in individual studies

Study quality	Design and risks of bias (RoB)
High	Randomized design with 0 or 1 RoB
Moderate	Randomized design with 2 or 3 RoB or observational study with <4 RoB and large magnitude of effect, observable dose–response gradient, or adjustments for all plausible residual confounding factors
Low	Randomized design with 4 or 5 RoB or observational study with <4 RoB
Very low	Randomized design with >6 RoB or observational study with ≥4 RoB

Defining the strength of the recommendations

After synthesizing the best evidence and its strength, the GDG reviewed the aggregate evidence, created a new or modified a previous recommendation (Figure 3), adjusted the strength of the recommendations depending on the evidence-to-decision framework, and provided rationale in the context of physical therapist practice.¹⁹

Figure 3.

Summary of Recommendations for Physical Therapist Management of Total Knee Arthroplasty (TKA). Recommendations in red indicate interventions that physical therapists are not recommended to routinely incorporate into post-TKA management. Recommendations in green indicate interventions that physical therapists are recommended to routinely incorporate into post-TKA management. Recommendations regarding the use of various treatment strategies for pain were combined when multiple interventions had the same strength of recommendation.

Figure 3.

Continued

Table 2 includes the operational definitions for the quality of evidence and links each recommendation strength to its visual representation and appropriate language stem.

Table 2.

Strength of recommendations

Visual	Strength of recommendation	Associated language stem	Definition
♦♦♦♦	Strong	Must or should	High-quality evidence: evidence from 2 or more high-quality studies with consistent findings
♦♦♦	Moderate	Should	Moderate-quality evidence: evidence from a single high-quality study or 2 or more moderate-quality studies with consistent findings or High-quality evidence that was downgraded using the Evidence to Decision (EtD) framework8
♦♦	Weak	May	Low-quality evidence: evidence from a single moderate-quality study or 2 or more low-quality studies with consistent findings or Moderate-quality evidence that was downgraded using the EtD framework8
♦	Consensus	May or should	Evidence from a single low-quality study or no supporting evidence or Low-quality evidence that was downgraded using the EtD framework8

Voting on the recommendations

GDG members voted upon the content and strength of each recommendation. When changes were made to the statements or strength of a recommendation on the basis of the evidence-to-decision framework, the GDG voted in person or electronically and provided an explanation in the rationale. A simple majority was used as the threshold for approval of all statements and strength designations.

Peer review and public commentary

Following the formation of a final draft, the CPG review draft was subjected to a 3-week peer review for additional input. A patient, a care partner, and external content experts from 14 relevant associations provided 79 comments (Suppl. Material 5) via an electronic structured review form. All peer reviewers were required to disclose any potential conflicts of interest, and none of these statements required management.

The draft was also subjected to a 2-week public comment period. The document was posted on the APTA website, and the opportunity was advertised through APTA communications and communities. Commenters consisted of 15 physical therapists from the United States and Canada and an associate professor of medicine. More than 25 public comments were received (Suppl. Material 5). Revisions to the draft were made in response to relevant comments.

Role of the funding source

APTA, which funded the project, selected the physical therapist members of the GDG from a pool of volunteer applicants and provided coordination but played no role in the design, conduct, and reporting of the recommendations.

Recommendations

Preoperative physical therapy

In patients with osteoarthritis of the knee, where TKA has been decided, does preoperative physical therapy affect postoperative outcomes?

Physical therapists should design and implement preoperative exercise programs for patients undergoing TKA to improve pre- and postoperative outcomes, including strength, flexibility, and endurance. Preoperative education may also incorporate neuroscience-based strategies to help manage pain and reduce procedure-related anxiety.

Evidence Quality: high.

Recommendation Strength: moderate ♦♦♦◊ (downgraded due to limited data on educational components and generally small to moderate effect sizes).

Action statement profile

Aggregate Evidence Quality: 12 high-quality studies^20–31 and 32 moderate-quality studies.^32–63

Rationale

Preoperative rehabilitation has been shown to improve early postoperative impairment-level and functional outcomes (0-1.5 months), including increased strength, improved function, and reduced pain. However, these early benefits tend to diminish over time, with limited evidence supporting sustained long-term effects.^{21,23–25,28,30,31} Current evidence has primarily examined outcomes related to functional performance, pain, and ROM There is little evidence regarding whether prehabilitation is related to other surgical outcomes such as hospital length of stay, readmissions, or surgical revision rates. Functional outcomes are somewhat variable; the majority of high-quality studies report better performance-based outcomes with prehabilitation, whereas patient-reported outcomes are less consistent. Importantly, no studies have demonstrated that preoperative exercise is inferior to alternative interventions or no intervention.

While the evidence strongly supports incorporating preoperative exercise to improve short-term outcomes,^{21,23–25,28,31} there is insufficient evidence to identify a specific exercise modality, clinical setting, or level of supervision (eg, in-person vs home-based or individual vs group sessions) as superior. Further, the amount of formal prehabilitation varies across studies, resulting in differences in cost and duration among programs. Therefore, the choice of intervention should consider the advantages and disadvantages of available options, as well as patient preferences. One high-quality study showed that integrating cognitive behavioral therapy and pain neuroscience education with joint mobilization may help reduce procedure-related anxiety and pain.³⁰

Overall, preoperative interventions appear to be safe, with no reported increase in postoperative complications or adverse events.

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• Improved postoperative strength, flexibility, endurance, functional outcomes, and reduced pain and anxiety, particularly in the early phases of rehabilitation.

Risks, harms, and costs

• Few studies directly compare physical therapy to no intervention and even fewer assess the impact of preoperative rehabilitation programs on postoperative utilization of rehabilitation services, limiting assessment of its economic value.

• Evidence of cost-effectiveness of prehabilitation is limited. Individual patients and health care systems incur some cost to provide prehabilitation before TKA, but these costs vary widely depending on the intensity and duration of the program. In Medicare’s bundled-payment programs, which cover the entire episode of care from the date of surgery through 90 days after discharge, prehabilitation is generally not included and therefore is typically billed under the typical fee-for-service reimbursement model. Hospitals may offer prehabilitation voluntarily, but they are not financially responsible for this service under the bundled program. In the United States, Medicare (which utilizes a bundled payment model) is the primary payer for approximately two-thirds of TKAs.⁶⁴

Benefit–harm assessment

• Preoperative physical therapy interventions appear to be safe, with no increase in postoperative complications or adverse events.

Feasibility

• The implementation of preoperative physical therapy is feasible and does not require specialized equipment or training beyond standard physical therapy practice.

Role of patient and client preferences

• Patient preferences should be considered, particularly concerning potential out-of-pocket costs and insurance limits on the number of covered rehabilitation visits.

Exclusions

• None identified.

Future research

• To better understand the economic value of preoperative physical therapy for patients with knee osteoarthritis undergoing TKA, more detailed research on the cost-effectiveness of prehabilitation and the impact of evolving payment models is needed.

• Future research should aim to identify the optimal dosage of prehabilitation that may improve TKA outcomes while minimizing added cost.

ROM interventions

In patients with osteoarthritis of the knee selected for TKA, which postoperative ROM interventions are associated with improved outcomes?

ROM Recommendation A: Physical therapists should not use continuous passive motion (CPM) for patients who have undergone primary, uncomplicated TKA

Evidence Quality: high.

Recommendation Strength: strong ♦♦♦♦.

Action statement profile

Aggregate Evidence Quality: 4 high-quality studies^65–68 and 12 moderate-quality studies.^69–80

ROM Recommendation B: Physical therapists should not routinely use bracing or splinting in the early postoperative period to increase knee ROM for patients who have undergone primary, uncomplicated TKA

Evidence Quality: moderate.

Recommendation Strength: moderate ♦♦♦◊.

Action statement profile

Aggregate Evidence Quality: 1 high-quality study⁸¹ and 4 moderate-quality studies.^82–85

ROM Recommendation C: Physical therapists should design and implement treatment interventions for patients undergoing TKA that include passive, active-assistive, and active ROM exercises to optimize recovery and improve functional outcomes of the affected knee

Evidence Quality: moderate.

Recommendation Strength: moderate ♦♦♦◊.

Action statement profile

Aggregate Evidence Quality: 2 moderate-quality studies^86,87 and 2 low-quality studies.^88,89

ROM Recommendation D: Physical therapists may use manual therapy with exercise and/or devices to augment active-assistive exercise to improve ROM in the early postoperative period

Evidence Quality: moderate.

Recommendation Strength: weak ♦♦◊◊ (downgraded due to limited evidence).

Action statement profile

Aggregate Evidence Quality: 3 high-quality studies^65,90,91 and 2 moderate-quality studies.^74,92

Manual Therapy: 1 high-quality study⁹⁰

Device-Assisted ROM: 2 high-quality studies^65,91 and 2 moderate-quality studies^75,92

Rationale

The collective evidence for CPM remains consistent with the 2020 TKA CPG, showing no meaningful clinical benefit. Therefore, the use of CPM is not justified given its cost, resource demands, and potential to disrupt postoperative care. Four high-quality studies demonstrated no significant short-term or long-term benefits of CPM devices.^65–68 Eight moderate-quality studies yielded mixed results that did not support routine use of CPM after TKA.^{69,72,73,75,78–80}

Available evidence from multiple studies indicates that bracing and splinting do not result in clinically meaningful improvements in knee ROM following primary TKA. Given the lack of demonstrated benefit and the potential for additional cost and burden to the patient, routine use of these interventions for this purpose is not recommended. Two moderate-quality studies compared bracing patients in knee extension to no brace for 2 and 8 days postoperatively and observed no differences in ROM; however, 1 study indicated improved patient-reported pain and function at 1 month in the braced group.^82,83 Two moderate-quality studies and 1 high-quality study compared splinting the patient in flexion versus full extension in the immediate postoperative period with no differences in knee ROM.^81,84,85 One study found improved knee flexion at 6 weeks, but no difference at 6 months, while the other 2 studies reported no differences in ROM between groups at 6 weeks.⁸⁵

Evidence suggests that no single ROM exercise method is superior following TKA. Two moderate-quality studies demonstrated a variety of passive, active-assistive, and active exercises improved knee ROM.^86,87 Chow and Ng compared active, passive, and proprioceptive neuromuscular facilitation interventions to improve knee flexion. All 3 groups demonstrated similar improvements in knee flexion ROM with no significant differences between groups.⁸⁷

In a high-quality study, manual therapy, consisting of joint mobilization, soft tissue mobilization, and incision massage, combined with exercise was compared to exercise alone, with both approaches resulting in improvements in pain, function, and patient satisfaction.⁹⁰ However, there was no significant difference in ROM observed between groups at 2 months.⁹⁰

Several devices, including cycle ergometers, active motion machines, and slide boards, have also been assessed for their impact on knee ROM. In a high-quality study, standard care was compared to the addition of either a slide board or CPM.⁶⁵ All groups showed improvement in knee flexion ROM and function at 3 and 6 months postoperatively, but there were no significant differences between them. Similarly, a moderate-quality study found no improvements in knee ROM, strength, or patient-reported function from the use of a cycle ergometer over standard exercise.⁹² A high-quality study compared a pedal-based exercise program to standard postoperative exercises and in the immediate postoperative period finding improved performance on functional tests and patient reported outcomes at 2 days, but no difference between groups at 2 weeks and 4 months postoperatively.⁹¹ Another moderate-quality study compared a low-resistance active motion device applied unilaterally and bilaterally to CPM; the group receiving bilateral active exercise demonstrated the greatest increase in knee flexion ROM.⁷⁵ Although no studies demonstrated that these devices are more effective than standard care interventions, they may still be considered as options to improve knee ROM.

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• Bracing into extension may have short-term effects on pain and function.

• Active, passive, and active-assistive exercises improve knee ROM and functional outcomes.

• Manual therapy and assistive devices can improve knee ROM and function, reduce early postoperative stiffness, and enhance patient engagement in rehabilitation.

Risks, harms, and costs for CPM

• May increase patient discomfort.

• Can reduce opportunities for active rehabilitation participation.

Risks, harms, and costs for bracing and/or splinting

• May prolong bedrest and limit natural movement patterns, restricting early mobility and gait training.

• Presents logistical challenges in coordinating donning/doffing protocols among care team members.

• May reduce patient adherence due to discomfort or confusion, leading to premature removal.

• Requires administrative coordination with durable medical equipment vendors to ensure timely provision and insurance coverage.

Risks, harms, and costs for manual therapy

• Effectiveness may vary depending on therapist skill and techniques utilized.

• Further data are needed on the influence of incision massage on wound healing.

• Associated with minimal cost and no reported harm.

Risks, harms, and costs for overall cost considerations

• The use of CPM, bracing, and/or splinting would likely incur both direct and indirect expenses (eg, equipment, maintenance, personnel), without evidence of significant or sustained long-term clinical benefit.

Benefit–harm assessment

• The preponderance of evidence suggests that CPM offers no consistent long-term improvements in function, ROM, or quality of life following uncomplicated TKA. Given the associated risks, inconvenience, and anticipated costs, the potential harms and resource burden outweigh the modest and transient benefits in most clinical scenarios.

• The lack of demonstrated clinical benefit, combined with the potential for delayed mobility and increased cost, suggests that the harms and burdens of bracing or splinting outweigh any potential short-term advantages in the early postoperative period.

• There is a preponderance of benefit for implementing ROM exercises after TKA. While benefits in ROM may not exceed those of standard care, manual and device-assisted approaches may support patient comfort and engagement. Given the low risk, these interventions may be considered when aligned with patient needs and available resources.

Feasibility

• Implementation of CPM requires specialized equipment, setup, and supervision, which may limit its feasibility in resource-limited settings. The need for equipment transport, staff time, and patient adherence adds logistical complexity. These factors, along with the lack of long-term benefit, make CPM a less practical intervention compared to more accessible, active rehabilitation interventions.

• Bracing and splinting require additional equipment and monitoring, increasing complexity and resource use in the postoperative setting without evidence of added clinical value.

• The implementation of ROM exercises is feasible in clinical or home settings with minimal resources.

• Manual therapy interventions may depend upon therapist technical skill, knowledge, and patient acceptance.

• The use of external devices to augment assisted ROM may be less practical in resource-limited environments.

Role of patient preferences

• Physical therapists should inform patients about the lack of evidence for CPM. Clinicians should consider patient preferences and individual goals, especially given the lack of definitive benefits with CPM use.

• Patients may prefer to avoid restrictive devices that limit early mobility and comfort, particularly in the absence of proven benefit. Shared decision-making should prioritize interventions that align with patient goals and recovery expectations.

• Various exercise options are available to improve knee ROM, and selection should be based on patient tolerance and preferences. Options for interventions should be discussed with patients with selections through a shared decision-making model.

Exclusions

• Patients with severe stiffness, arthrofibrosis, or revision TKA may require individualized rehabilitation strategies.

Future research

• Some subpopulations may benefit from CPM and/or targeting bracing or splinting. This could be explored with studies large enough to allow subgroup analyses or by narrowing inclusion criteria. Examples may be those with TKA revisions or those with particularly poor preoperative ROM.

• Cost-effectiveness and patient-centered outcomes should be prioritized in future investigations.

Nonpharmacological pain interventions

In patients with osteoarthritis of the knee selected for TKA, are nonpharmacological pain interventions associated with improved patient-reported outcomes?

Pain Recommendation A: Physical therapists should teach and encourage use of cryotherapy for early postoperative pain management for patients who have undergone TKA

Evidence Quality: moderate.

Recommendation Strength: moderate ♦♦♦◊.

Action statement profile

Aggregate Evidence Quality: 18 moderate-quality studies.^93–110

Pain Recommendation B: Physical therapists may use transcutaneous electrical nerve stimulation (TENS) (acute and subacute phases), Kinesio Taping (Kinesio, Albuquerque, NM, USA) (acute phase), manual therapy (time frame not specified), and/or psychologically informed techniques (time frame not specified) to decrease pain after TKA

Evidence Quality: moderate.

Recommendation Strength: weak ♦♦◊◊ (downgraded due to low certainty of evidence).

Action statement profile

Aggregate Evidence Quality: 3 high-quality studies^90,111,112 and 24 moderate-quality studies.^{93–110,113–118}

Cryotherapy: 18 moderate-quality studies (5 using computer-assisted cryotherapy).^93–110

TENS: 1 high-quality study¹¹¹ and 1 moderate-quality study.¹¹³

Kinesio Taping: 2 moderate-quality studies.^95,114

Manual Therapy: 1 high-quality study.⁹⁰

Psychologically Informed Techniques: 1 high-quality study¹¹² and 4 moderate-quality studies.^115–118

Rationale

Cryotherapy

Eighteen moderate-quality studies examined the use of cryotherapy after TKA.

Five studies examined the use of computer-assisted cryotherapy.^{94,96,97,99,100} One compared to a control found improvements in pain and a reduction in opioid use.⁹⁴ Two studies found greater improvements in pain compared to a cold pack, but total treatment time differed.^96,97 A similar study comparing computer-assisted cryotherapy for 2 h 2 times per day compared to cold packs for 20 min 3 times per day found a reduction in pain with movement in the computer-assisted cryotherapy group.⁹⁷ Another study that compared 2 different temperatures of cryotherapy found no difference in pain but less opioid use in the group receiving 10 to 12 °C versus 21 °C.¹⁰⁰

One study comparing cold packs used every 2 h for 12 to 15 min to Kinesio Tape found that cold packs were better for edema but no better for pain.⁹⁵

One study found that use of the Cryocompression Game Ready device (Avanos Medical, Inc. Alpharetta, GA, USA) 6 times per day for 20 min at 5 °C was no better than the use of crushed ice bags.⁹³

One study comparing cold packs applied to the knee versus cold packs over the palm found no difference in pain with knee flexion.⁹⁸

Transcutaneous electrical nerve stimulation

This recommendation has been downgraded due to small effect sizes in the supporting evidence. One high-quality study and 1 moderate-quality study were reviewed.^111,113 Both studies showed that using TENS in the acute and subacute phases after surgery (up to 6 weeks postoperatively) could improve visual analog scale pain ratings after walking.^111,113 Acupuncture-like TENS was better at decreasing pain at rest than standard TENS in the first 2 weeks following surgery.¹¹³ There was no difference in pain scores when TENS was applied daily for a short duration (45 s).¹¹¹

Kinesio Taping

This recommendation was downgraded due to lack of certainty of the supporting evidence. Two moderate-quality studies were reviewed.^95,114 Both studies showed that patients who had Kinesio Taping in the first week following surgery had decreased pain within the first 1 to 2 weeks postoperatively compared to patients who did not have taping. However, 1 study continued to follow patients until 3 months postoperatively, and there was no between-group difference in pain at the 3-month time point.⁹⁵

Manual therapy

This recommendation was downgraded due to the small sample size of the supporting study. One high-quality study was reviewed.⁹⁰ This study showed statistically significant improvements in postoperative pain ratings when patients received a multimodal treatment that included manual therapy when compared to a group whose treatment did not include manual therapy.

Psychologically informed techniques

One high-quality study and 2 moderate-quality studies examined the use of cognitive-behavioral therapy following TKA.^112,116,118 Other interventions investigated include pain neuroscience education (1 moderate-quality study), Videoinsight art video (1 moderate-quality study), and biopsychosocial model–based rehabilitation (1 low-quality study).^115,117,119 In the 1 high-quality study of cognitive-behavioral therapy, kinesiophobia, perceptions of pain, and quality of life were improved following cognitive-behavioral therapy at the 1- and 6-month outcome measurements compared to standard therapy. An inclusion criterion for this study was a high level of kinesiophobia defined as a score greater than 37 on the Tampa Scale for Kinesiophobia, which may limit its generalizability to the overall TKA population.¹¹² In the moderate-quality studies, outcomes that were improved after psychologically informed techniques as compared to other interventions included attention to pain, pain catastrophizing, anxiety, depression, and pain with activity.^116,118

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• Cryotherapy, TENS, Kinesio Taping, and manual therapy may contribute to small decreases in postoperative pain when used in a multimodal physical therapy plan of care.

• Psychologically informed techniques may help to improve kinesiophobia, pain catastrophizing, and quality of life for persons with high levels of kinesiophobia.

Risks, harms, and costs

• None of the included studies reported significant adverse events compared to control or other modalities.

• Risks appear to be low when treatments are applied by a trained physical therapist.

• Costs for implementing these treatments vary: cryocompression braces and computer-assisted therapy units are expensive, while TENS units and tape are inexpensive and widely available. Manual therapy interventions can be applied during routine physical therapy treatment sessions.

• Psychologically informed techniques may cost more than standard physical therapy because these may require interprofessional collaboration or advanced training for the physical therapist.

Benefit–harm assessment

• Risks and harms are low. Physical therapists and patients should discuss the potential benefits of these treatment strategies when determining their usage.

• Given the available evidence, physical therapists should consider restricting the use of cryotherapy, TENS, Kinesio Taping, and manual therapy to the early postoperative phases and/or in patients for whom pain is limiting function.

• Psychologically informed techniques may be specifically beneficial for patients with high levels of kinesiophobia.

Feasibility

• Cryotherapy, TENS, Kinesio Taping, and manual therapy have been used extensively and are feasible interventions.

• The application of Kinesio Taping and psychologically informed therapy may require physical therapists to undergo additional training in order to apply these treatments during routine physical therapy sessions.

• Psychologically informed therapy may involve collaboration with other professions.

Role of patient preferences

• Patients’ preferences for pain-relieving modalities should be considered before applying cryotherapy, TENS, Kinesio Taping, or manual therapy.

• Physical therapists should confer with patients who demonstrate high levels of kinesiophobia regarding the option for psychologically informed treatment strategies in their rehabilitation.

Exclusions

• Clinicians should not utilize cryotherapy or TENS for patients who present with contraindications to these modalities.

• Taping should not be used for patients with adhesive allergies or a history of tape reactions.

• Manual therapy should not be utilized for patients with contraindications or by untrained therapists.

• Persons with low levels of kinesiophobia (<37 on the Tampa Scale for Kinesiophobia) may be less likely to benefit from cognitive behavioral strategies.

Future research

• Further high-quality research is needed to discover optimal treatment parameters and timing for cryotherapy, TENS, Kinesio Taping, and manual therapy.

• Future research is needed to identify best practice for taping application techniques and to determine the effects of taping when it is applied >1 week postoperatively.

• Additional research is needed to compare the use of Kinesio Tape to other pain-relieving interventions.

• Future research on manual therapy should aim to identify optimal dosing and specific techniques that maximize postoperative pain relief and improve pain experience after TKA.

• Further high-quality research is needed to discover optimal treatment parameters for psychologically informed interventions and to identify sub-groups of patients who are most likely to benefit from these interventions.

Swelling/edema management strategies

In patients with osteoarthritis of the knee selected for TKA, which swelling/edema management strategies improve patient outcomes postoperatively?

Swelling/Edema Recommendation A: To minimize risk of immediate postoperative swelling/edema, physical therapists and/or other team members should prescribe cryotherapy treatment and teach positioning of the surgical limb in an elevated position with 30 to 90 degrees of knee flexion during the early postoperative period after TKA

Evidence Quality: high.

Recommendation Strength: moderate ♦♦♦◊ (downgraded due to certainty of evidence).

Action statement profile

Aggregate Evidence Quality: 2 high-quality studies^81,120 and 15 moderate-quality studies.^{85,93–95,97,99–101,104,106–110,121,122}

Cryotherapy: 12 moderate-quality studies.^{93–95,97,99–101,104,  106–109}

Limb Positioning: 2 high-quality studies^81,120 and 3 moderate-quality studies.^85,121,122

Swelling/Edema Recommendation B: Physical therapists may consider Kinesio taping after uncomplicated TKA to reduce postoperative swelling/edema; however, evidence is mixed regarding its benefit

Evidence Quality: moderate.

Recommendation Strength: weak ♦♦◊◊ (downgraded due to heterogeneity of evidence).

Action statement profile

Aggregate Evidence Quality: 3 moderate-quality studies.^95,114,123

Swelling/Edema Recommendation C: In the absence of sufficient quality evidence, it is the opinion of this work group that physical therapists should not routinely use manual lymphatic drainage (MLD), compression dressings, or CPM to reduce postoperative swelling/edema following TKA, as these interventions have not been proven effective

Evidence Quality: low.

Recommendation Strength: consensus ♦◊◊◊ (downgraded due to heterogeneity of evidence).

Action statement profile

Aggregate Evidence Quality: 4 moderate-quality studies.^123–126

Compression: 1 moderate-quality study.¹²⁴

Manual Lymphatic Drainage: 2 conflicting, moderate-quality studies.^123,125

Continuous Passive Motion: 1 moderate-quality study.¹²⁶

Rationale

Cryotherapy

Physical therapists should consider prescribing cryotherapy treatment for postoperative management of swelling/edema following TKA. Current literature does not identify one specific modality of cryotherapy as superior to others in reducing swelling/edema. Therefore, the advantages and disadvantages of each option should be carefully evaluated when selecting a treatment method. Variability in study protocols limits recommendations regarding the optimal timing, duration, frequency, or method of application. Additionally, there is insufficient evidence to specify when to initiate cryotherapy after surgery or how long it should be continued.

Limb positioning

Early postoperative positioning of the surgical limb in an elevated position with the knee in flexion (typically 30°-90°) has been shown to reduce knee swelling/edema and both total and hidden blood loss, while also improving early ROM. These benefits are generally observed within the first 72 hours postoperatively, and the intervention has not been associated with increased complications. Supporting evidence includes 2 high-quality studies^81,120 and 3 moderate-quality studies.^85,121,122 Due to variability in study interventions, the work group is unable to recommend an optimal duration, frequency, or degree of knee flexion.

Kinesio Taping

The evidence surrounding Kinesio Taping remains inconclusive. Two moderate-quality studies reported no significant benefit of Kinesio Taping for reducing postoperative swelling/edema, while 1 moderate-quality study demonstrated short-term improvements in edema.^95,114,123 Given this variability, the overall effectiveness of Kinesio Taping in managing postoperative swelling/edema remains uncertain. Clinicians may consider its use on a case-by-case basis following uncomplicated TKAs but should do so with an understanding of the current limitations in the evidence.

Manual lymphatic drainage

The benefits of MLD for postoperative management of swelling/edema after TKA remain unclear, with inconsistent evidence from both moderate- and low-quality studies. One moderate-quality study reported improvement in edema on postoperative day 4, but no sustained benefit while another moderate-quality study found no significant effect on swelling/edema.^123,125 A low-quality study concluded that MLD is not effective for swelling/edema reduction.¹²⁷ Furthermore, when analyzing evidence located as part of this CPG (Suppl. Material 4), we found no significant evidence supporting the use of MLD to reduce postoperative swelling/edema.

Compression

Compression dressings applied during the first 24 h after TKA do not appear to reduce swelling/edema (moderate-quality study).¹²⁴

Continuous passive motion

The use of a CPM device does not appear to reduce postoperative edema. One moderate-quality study reported no statistically significant difference in edema outcomes between the group receiving CPM and the control group.¹²⁶ On the basis of this finding and in the absence of consistent or compelling evidence, there is currently insufficient evidence to support the use of CPM for edema control.

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• Cryotherapy may result in short-term postoperative improvements in pain, knee flexion, postoperative swelling/edema, and decreased opioid use compared to no cryotherapy; possible modest improvement in early mobilization and walking distance.

• Early postoperative positioning of the knee in an elevated position with 30 to 90 degrees of knee flexion helps reduce early postoperative swelling/edema and is associated with reduced blood loss and improved knee ROM in the early phase of recovery following TKA.

Risks, harms, and costs

None of the included studies reported significant adverse events compared to control or other modalities. Risks appear to be low for all treatment options when implemented by trained physical therapists.

• When using cryotherapy, while rare, complications like skin irritation, cold-induced injury (eg, frostbite), and delayed wound healing may occur; these risks can be mitigated through appropriate screening, monitoring, and patient education.

• Knee flexion positioning may increase the risk of postoperative knee extension loss and should be implemented with caution. Current evidence does not show an increased risk of fixed flexion contractures; however, the generalizability of these findings is limited by delayed mobilization protocols and prolonged inpatient stays in existing studies. It is recommended that therapists incorporate targeted ROM exercises aimed at improving knee extension while implementing knee flexion positioning strategies.

• Costs for implementing these treatment strategies can vary depending on the intervention and device selected. High-cost cryotherapy devices (eg, computer-assisted or continuous flow systems) may improve patient experience but could be cost-prohibitive in low-resource or outpatient settings. Low-cost alternatives (eg, ice packs) are more accessible but may offer less consistent cooling. Limb positioning devices and Kinesio Tape are generally low cost and widely available.

• The use of MLD, compression dressings, and CPM would likely incur both direct and indirect expenses (eg, equipment and personnel), without evidence of significant or sustained long-term clinical benefit.

Benefit–harm assessment

• The overall benefits and harms favor the use of cryotherapy and early limb positioning following TKA, as these interventions demonstrate meaningful improvements in early recovery with minimal risk.

• In contrast, Kinesio Taping, MLD, compression dressings, and CPM offer uncertain benefits and may increase cost or treatment burden without improving outcomes.

• Therefore, the benefit–harm assessment supports prioritizing evidence-based, low-risk interventions, while avoiding routine use of low-value modalities.

Feasibility

• Cryotherapy and postoperative limb positioning are practical, low-cost interventions suitable for both inpatient and outpatient settings. Basic methods (eg, ice or gel packs) are widely accessible, require minimal equipment, and are simple to apply. Advanced systems (eg, Cryo Cuffs [Aircast; My Cold Therapy, Charlotte, NC, USA], continuous cold flow, computer-assisted devices) involve higher costs and equipment needs but may improve ease of use and patient satisfaction. Minimal staff training is required, and protocols can be tailored to patient needs and facility resources. Overall, both cryotherapy and limb positioning are feasible and scalable interventions for routine postoperative care after TKA.

Role of patient preferences

• Patients’ preferences should be considered when selecting interventions for the management of postoperative swelling/edema. When utilizing cryotherapy, limb positioning, and Kinesio Taping, preferences may be influenced by factors such as cost, insurance coverage, access to equipment, storage needs, physical ability, prior experience, and comfort.

• Similarly, clinicians may consider patient preferences when using MLD, compression dressings, or CPM, as these interventions may not improve swelling/edema or functional outcomes postoperatively. Patients should be informed that evidence is conflicting or lacking—some may value these treatments for comfort or past experience, while others may choose to avoid them due to unclear benefit.

Exclusions

• Patients with cold sensitivity, impaired sensation, impaired circulation, or skin concerns may require adjusted protocols.

• Taping is contraindicated in patients with known adhesive allergies, a history of adverse skin reactions to tape, or compromised skin integrity.

• This recommendation applies to typical postoperative edema management following TKA. Patients with severe stiffness, arthrofibrosis, or prior interventions (eg, manipulation under anesthesia) represent atypical cases and may require individualized approaches to cryotherapy and limb positioning.

Future research

High-quality randomized controlled trials with longer follow-up are needed to improve guidance on cryotherapy and limb positioning after TKA. Key research priorities include

• Defining optimal timing, frequency, and duration of cryotherapy for maximal benefit.

• Comparing cost-effectiveness across cryotherapy modalities, from basic ice packs to advanced devices.

• Identifying patient subgroups (eg, high body mass index, comorbidities, preoperative swelling/edema) who may benefit most.

• Evaluating effects on early mobilization, functional recovery, opioid use, and health care outcomes such as readmissions and length of stay.

• Conducting larger trials comparing degrees of knee flexion, duration, and frequency of positioning to clarify effectiveness in reducing swelling/edema.

• Inclusion of economic analysis and patient-centered outcomes will be essential to establish the value and generalizability of these interventions in contemporary TKA care pathways.

High-quality randomized controlled trials are needed to clarify the effectiveness of Kinesio Taping, MLD, compression dressings, and CPM in reducing postoperative swelling/edema after TKA. Future studies should

• Determine optimal treatment protocols, including timing, frequency, and duration.

• Identify patient subgroups who may benefit based on factors such as baseline edema or comorbidities.

• Evaluate patient-centered outcomes including comfort, satisfaction, and functional recovery.

• Incorporate long-term follow-up and standardized outcome measures.

• Include economic analyses to understand cost-effectiveness.

• Explore potential synergistic effects when combined with other modalities like cryotherapy or therapeutic positioning.

• Further research should develop methods to distinguish intra-articular swelling (effusion) from extra-articular swelling (edema) since current clinical measures like circumference measurements cannot do this accurately. This would allow for the delineation of mechanistic impacts between effusion and edema on recovery as well as determine which interventions more efficaciously impact effusion versus edema.

Physical activity interventions

In patients with osteoarthritis of the knee selected for TKA, which postoperative physical activities are associated with improved outcomes?

Physical therapists should encourage early physical activity and develop a plan to progressively increase physical activity based on safety, functional tolerance, physiological response, and collaborative goal setting with patients who have undergone TKA

Evidence Quality: moderate.

Recommendation Strength: moderate ♦♦♦◊.

Action statement profile

Aggregate Evidence Quality: 1 high-quality study¹²⁸ and 9 moderate-quality studies.^129–137

Rationale

One high-quality article and 1 moderate-quality article examined the outcomes of a physical activity intervention targeting a progressive increase in physical activity (steps per day and moderate to vigorous physical activity) using activity trackers and collaborative goal setting with patients.^128,129

Christiansen et al included US veterans who were 2 to 4 weeks after TKA.¹²⁸ The intervention group received a telehealth-based physical activity behavior change intervention focused on education, self-monitoring, feedback barrier and facilitator identification, problem solving, action planning, and encouragement. The control arm received the same number of sessions, but emphasis was placed on health education. The physical activity behavior change intervention group had more daily steps compared to control at the end of intervention. There were no long-term differences in physical activity at 6 months; however, a majority of participants walked greater than what has been shown to be protective against functional limitation development in people with knee osteoarthritis (6000 steps per day).¹³⁸

Christiansen et al found that patients who received a physical therapist–administered physical activity intervention accumulated more steps per day and spent more minutes per week in moderate to vigorous physical activity at 6 months compared to a control intervention.¹²⁹ After outpatient physical therapy discharge, patients received monthly phone calls for 6 months to update steps goals and promote sustainability of the physical activity intervention.

One moderate-quality article found no differences at 12 weeks between patients who received an enhanced physical activity intervention consisting of goal setting, problem solving, and use of motivational interviewing techniques to promote 150 min of moderate-intensity aerobic activity per week.¹³⁰ A second moderate-quality article found that patients who received a physical activity intervention based on motivational interviewing principles along with financial incentives to increase physical activity increased their steps per day by 1808 as well as increased weekly physical activity by 39 min.¹³¹

In addition to physical activity interventions, moderate-quality evidence indicates that activities such as stationary cycling, aquatic exercise, and Tai chi are safe in the early postoperative period and demonstrate positive effects on quality of life, physical function, walking ability, knee ROM, and strength.^132–136 Finally, 1 year after TKA, moderate-quality evidence supports participating in hiking to improve stair-climbing performance and self-reported function.¹³⁷ No studies were identified directly comparing one method of physical activity to another.

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• Increased physical activity levels may lead to decreased risk of mortality and development of comorbidities.

• Increased physical activity levels may lead to improved activity and participation levels.

• Increased physical activity levels may lead to improved quality of life.

Risks, harms, and costs

• No increased risks were identified when progression of physical activity was monitored for safety, functional tolerance, and physiological response.

• Potential increased risk for soreness, pain, and injury.

• Additional cost may be associated with the health care provider’s time to deliver a physical activity intervention as well as potential costs associated with activity tracking.

Benefit–harm assessment

• A preponderance of evidence supports the benefits of implementing a structured plan to increase physical activity after TKA given minimal potential risks and the positive overall impact on individuals’ health and quality of life.

Feasibility

• Feasibility may be limited by resources related to cost as well as the intervention may need to be delivered over a longer period of time to increase sustainability.

• Physical activity programs are feasible to implement using a telehealth-delivered intervention.

Role of patient preferences

• Physical activity goal setting should be based upon a collaborative process with the individual patient. Incorporation of activities such as stationary cycling, aquatic exercise, and Tai chi should be based on preferences.

Exclusions

• None were identified.

Future research

• Future research should determine optimal methods to improve physical activity levels after TKA and methods to increase sustainment of increasing physical activity.

• Furthermore, future studies should examine the effects of specific types of physical activity (eg, cycling) on both short- and long-term outcomes after TKA including safety.

Movement pattern retraining interventions

In patients with osteoarthritis of the knee selected for TKA, which postoperative movement pattern retraining interventions are associated with improved patient outcomes?

Physical therapists should include motor function training in their interventions for patients who have undergone TKA. Interventions can include dynamic balance training, computer or app-assisted gait retraining, and movement training with feedback

Evidence Quality: high.

Recommendation Strength: strong ♦♦♦♦.

Action statement profile

Aggregate Evidence Quality: 9 high-quality studies^139–147 and 12 moderate-quality studies.^148–159

Rationale

Nine high-quality and 12 moderate-quality studies investigated the effects of various types of movement pattern retraining on balance, walking, and physical function after TKA. Interventions varied from in-clinic to home-based. Many studies did not use any specialized equipment, but some used apps, virtual reality, and other technologies. A lot of studies included some type of balance and/or sensorimotor training using uneven surfaces, agility exercises, varying bases of support, and similar approaches. Many studies also incorporated weight-bearing functional tasks including sit-to-stand transfers and stair negotiation into their exercise programs.

The included studies vary with respect to whether real-time feedback regarding movement patterns was provided to participants, but 6 of the included studies (3 high-quality and 3 moderate-quality studies) appear to have incorporated real-time feedback and therefore may most closely meet the definition of movement pattern retraining.^{142,144,147,152,154,156} Two high-quality studies investigated movement pattern training versus usual physical therapy after TKA but found conflicting results.^142,147 Christiansen et al found that 5 times sit-to-stand time and peak knee extension moments during gait favored the intervention group at 6 months, while Bade et al mostly found equivocal outcomes between groups. In a study that only included women, Lee and colleagues compared dynamic balance retraining with versus without real-time visual feedback and found that the group that received visual feedback had better physical function, gait, and balance after intervention (4 weeks).¹⁵² Three studies provided real-time feedback using technologies. Two moderate-quality studies found conflicting short-term results when using gamification as an intervention, but this may be because the study of Choi and Shin also involved constraint-induced movement therapy.^154,156 One high-quality study used an external shoe orthotic device to provide feedback on gait biomechanics and found improved function, walking ability, and pain at 1 year compared to use of a sham device.¹⁴⁴

Among the included high-quality studies, the majority found outcomes favoring movement pattern or functional retraining with respect to gait, balance, and physical function.^{139,141–144} One high-quality study found mixed results for balance, with some balance outcomes favoring a platform-based balance program versus standard rehabilitation but other balance outcomes being similar between groups.¹⁴⁶ Three high-quality studies did not find many significant between-group differences; however, 1 of those studies was a feasibility study that was not powered to detect significant between-group differences, and another compared 2 different approaches to balance training so both groups received the training in some manner.^140,145,147

The included moderate-quality studies mostly favored movement pattern or balance retraining interventions, with most only examining outcomes immediately after intervention at 4 to 8 weeks after baseline and only 1 examining outcomes at 6 months or longer.^{151–153,155–158} Among the 4 moderate-quality studies that did not find significant between-group differences, some had considerable methodological concerns including very high participant attrition and improper randomization scheme.^{149,150,154,159}

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• Improvement in balance.

• Improvement in walking function.

• Improvement in physical function, especially performance-based measures.

• Improvement in activities and participation (eg, getting in and out of car, shopping, household duties).

Risks, harms, and costs

• No expected risk or harms are associated with this recommendation.

• Team members should be aware of potential complications after TKA that may affect exercise including incision healing, thromboembolism, and joint stiffness/arthrofibrosis. Some of the more advanced training programs that include app-based training, or weight-bearing biofeedback may be cost- and resource-prohibitive for some clinical settings.

Benefit–harm assessment

• A preponderance of evidence supports including motor function training. The individualization of progression to match the patient’s goals, abilities, and physiological response should include documentation of objective baseline data, the patient’s goals, and plan of care (interventions, dosage, frequency, and duration). This includes the use of appropriate outcomes to demonstrate patient response to the specific approach.

Feasibility

• Feasibility of movement pattern training depends somewhat upon whether the physical therapist and patient intend to use some type of specialized device or digital health tool. Existing research has shown promise for some devices that may not be readily available or financially feasible, but several studies have also shown benefits for intervention programs that are easily and safely implemented within most outpatient clinic or home-based settings.

Role of patient preferences

• Patient preferences should be considered regarding whether movement pattern retraining interventions should incorporate the use of devices or technologies.

Exclusions

• None were identified.

Future research

• The long-term impact of normalizing movement patterns or improving balance after TKA remains unclear. Future research should determine whether improving movement symmetry reduces long-term sequelae on the surgical and nonsurgical limbs and whether improving balance after TKA reduces fall prevalence and long-term morbidity.

• As technology improves, the use of biofeedback-based movement interventions may become more applicable for this patient population. Future research is warranted to determine the feasibility of such systems and long-term impact.

Neuromuscular electrical stimulation interventions

In patients with osteoarthritis of the knee selected for TKA, does postoperative use of neuromuscular electronic stimulation around the knee/quadriceps area improve postoperative outcomes?

Physical therapists should apply neuromuscular electrical stimulation (NMES) at least daily to the quadriceps for patients who have undergone TKA, initiated in the early postoperative period at the highest tolerable intensity, to improve quadriceps muscle strength, gait performance, and performance-based outcomes

Evidence Quality: moderate.

Recommendation Strength: moderate ♦♦♦◊.

Action statement profile

Aggregate Evidence Quality: 6 moderate-quality studies^160–165 and 2 low-quality studies.^166,167

Rationale

Six moderate-quality studies evaluated the effectiveness of NMES versus no NMES in patients following TKA.^160–165 Two studies demonstrated that NMES improved quadriceps and hamstring maximum voluntary isometric contraction from 2 to 52 weeks after TKA.^162,163 Four studies reported greater improvements in walking ability, stair-climbing performance, and patient-reported outcomes with NMES compared to no NMES use during the same period.^160–163 Postoperative ROM did not differ significantly between NMES and no NMES groups from 2 to 52 weeks after TKA.^162–164 Initiating NMES as early as postoperative day 2, applying it more frequently (1 or 2 times per day), and maximizing cumulative intensity were associated with improved outcomes.^160–163

One moderate-quality study comparing NMES to sham NMES found that at 12 weeks, the NMES group reported reduced knee pain and stiffness and improved function.¹⁶⁵ Another moderate-quality study showed that patients receiving NMES experienced statistically significant improvements in patient-reported outcomes, perceived physical health status, and walking speed.¹⁶¹ Conversely, 2 other moderate-quality studies did not identify significant differences in patient-reported outcomes or perceived physical health status.^160,164

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• Improvement in quadriceps and hamstrings maximum voluntary isometric contractions from 2 to 52 weeks after TKA.

• Improvement in walking and stair-climbing performance.

Risks, harms, and costs

• The financial cost of using NMES and its availability to patients may be prohibitive for patients.

• Pain/discomfort with use.

Benefit–harm assessment

• There is a preponderance of benefit for the use of NMES following TKA, particularly for patients with quadriceps muscle activation deficits. However, considerations such as cost, access, and patient tolerance must be weighed against these benefits.

Feasibility

• Cost, access to NMES units, and patient tolerance may limit adoption. Patients after TKA who are most likely to benefit are those with quadriceps muscle activation deficits, often measured in terms of a quadriceps extensor lag or quadriceps activation battery. NMES should be applied regularly for at least a minimum of 3 weeks.

Role of patient preferences

• Patients should be educated on the benefits of NMES and determine its use in a shared decision-making model.

Exclusions

• NMES should not be used for patients with demand-type pacemakers, active cancer, or deep vein thrombosis.

Future research

• Although current evidence supports the use of NMES after TKA, additional research might continue to refine NMES benefits by understanding patient factors supportive of NMES use, optimal dosage, stimulation parameters, application with and without concurrent muscle contraction, mechanisms explaining NMES efficacy, adjuncts to NMES (eg, nutritional supplementation), and when to discontinue NMES.

Strength training interventions

In patients with osteoarthritis of the knee selected for TKA, does postoperative strength training significantly improve postoperative outcomes?

Physical therapists should design, implement, and teach patients who have undergone TKA progressive strength training and exercise programs beginning in the early postacute period to improve function, strength, and ROM

Evidence Quality: high.

Recommendation Strength: strong ♦♦♦♦.

Action statement profile

Aggregate Evidence Quality: 7 high-quality studies^21,168–173 and 1 moderate-quality study.^{151,159,174–188}

Rationale

Seven high-quality studies and 17 moderate-quality studies support the benefit of postoperative progressive, resistance exercise programs on muscle strength, functional performance, and balance.^{21,151,159,168–187} The type, intensity, timing, and delivery model of the exercise program vary in the studies though all demonstrated benefit.

Specified progressive resistance exercise programs shown to provide significant benefit include the combined use of closed and open-chain exercises, combined use of eccentric and concentric resistance exercises, use of isotonic and isokinetic resistance exercise, and use of exercise bands.^{151,169,171,172,176,185,186} Introducing progressive exercises early in the inpatient, postacute phase of recovery was also shown to safely provide benefit.^151,178,179 Use of auditory and visual feedback with typical postoperative isometric quad exercises showed greater improvements in Timed Up and Go Test scores, gait speed, and function.¹⁷⁹ Karapınar et al found benefit for both a high-intensity exercise program and a low-intensity exercise program when delivered in the inpatient setting.¹⁷⁸ Both groups demonstrated improvement in pain scores while the high-intensity group demonstrated improved stiffness and function. Similarly, Bade et al showed benefit for both high-intensity and low-intensity resistance training though not significant difference between the 2.¹⁶⁸ The authors noted that the effectiveness of high-intensity resistance training may be limited by arthrogenic inhibition of the quadriceps (muscle activation deficits) in the early postoperative period.¹⁶⁸ To date, no study has compared criteria used for progression; however, Bade et al did report progression criteria that consisted of monitoring soreness, pain, ROM, swelling/edema, and self-reported function to guide progression of intensity.

Several articles tested the addition of specific exercises into a typical postoperative exercise regimen.^{159,175,177,183} Schache et al added in specific hip abductor exercises which did not significantly improve function, strength, or patient satisfaction over general functional strengthening exercises.¹⁸³ Conversely, Do and Yim found that the inclusion of hip muscle strengthening versus quad and active ROM training can significantly improve physical function and gait.¹⁷⁰ Bily et al examined a computer-controlled leg press exercise with optional vibration and found that it was less time consuming than conventional physical therapy but did not have significant differences in quad strength, pain or functional outcomes for participants.¹⁷⁵ Maximal strength training did seem to show significant difference in strength of targeted muscle groups but not in overall functional gains.¹⁷⁷ Finally, Karadüz et al found that including core stabilization exercises and balance training were beneficial for balance, function, and ROM.¹⁵⁹

Further evidence is needed to assess the benefit of resistance training in later-stage recovery (>2 months postoperatively). Piva et al showed functional improvement from the physical therapy intervention when compared to community exercise groups or no intervention, but there was not perceived improvement by patient self-report.¹⁸²

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• Improvement in muscle strength.

• Improvement in functional activities.

• Increased gait speed.

• Improved balance.

• Improved functional knee ROM.

Risks, harms, and costs

• Early postoperative high-intensity resistance training after TKA does not have harms or risks when the therapist follows appropriate progression criteria (eg, avoiding excessive swelling/edema, pain, or prolonged soreness following intervention) and educates the patient accordingly.

• In the absence of appropriate criteria, overly aggressive progression can exacerbate pain and swelling/edema.

• Team members should be aware of potential complications after TKA that may affect exercise including incision healing, thromboembolism, and joint stiffness/arthrofibrosis.

Benefit–harm assessment

• There is a preponderance of benefit for this recommendation. Harms are minimal as long as appropriate progression criteria are followed.

Feasibility

• Feasibility of a postoperative exercise program will vary on the basis of the setting, supplies, and timing of therapist interaction with the patient. However, due to the preponderance of data showing benefit from various kinds of exercise, a program can be chosen and tailored by the therapist to meet the needs of individual patients within the constraints of the work setting with the resources available.

Role of patient preferences

• Exercise programs can be adjusted on the basis of patient preferences and tolerance. Improvements in strength, function, and gait can be gained through different methods.

Exclusions

• None were identified.

Future research

• Future studies should evaluate the impact of muscle activation deficits on the effectiveness of early progressive resistance exercise in terms of muscle strength gains and functional outcomes.

• Additional work should focus on the optimal timing of resistance training, potentially targeting later postoperative recovery when muscle activation deficits have resolved.

Physical therapy delivery methods

In patients with osteoarthritis of the knee selected for TKA, what delivery methods of postoperative physical therapy are associated with improved outcomes?

Delivery Methods Recommendation A: Supervised physical therapist management should be provided for patients who have undergone TKA. The optimal setting should be determined by patient safety, mobility, and environmental and personal factors

Evidence Quality: moderate.

Recommendation Strength: moderate ♦♦♦◊ (downgraded due to small effects and uncertainty in results).

Action statement profile

Aggregate Evidence Quality: 2 high-quality studies^112,189 and 17 moderate-quality studies.^{86,182,190–204}

Delivery Methods Recommendation B: Physical therapists may use group-based or individual-based physical therapy sessions for patients who have undergone TKA

Evidence Quality: moderate.

Recommendation Strength: weak ♦♦◊◊ (downgraded due to heterogeneity in study results and issues with study design).

Action statement profile

Aggregate Evidence Quality: 1 high-quality study²⁰⁵ and 5 moderate-quality studies.^{182,206–209}

Delivery Methods Recommendation C: Physical therapists and patients should consider use of digital health tools after TKA, either in addition to in-clinic care or as an alternative to in-clinic care

Evidence Quality: high.

Recommendation Strength: moderate ♦♦♦◊ (downgraded due to wide variation in interventions being compared and heterogeneity in outcomes measured).

Action statement profile

Aggregate Evidence Quality: 3 high-quality studies^128,189,210 and 25 moderate-quality studies.^{38,117,129,154,174,202,211–229}

Rationale

Supervision of postoperative physical therapy

In the original 2020 CPG, the 2 available high- and moderate-quality trials found that supervised physical therapy (physical therapy care that is initiated and monitored, and individually tailored by a licensed physical therapist) was superior to unsupervised (generic exercise programs that are not regularly monitored or progressed by a licensed physical therapist). More recent moderate-quality studies examining supervised versus unsupervised exercise after TKA have mostly found equivocal outcomes, although standard outpatient rehabilitation was associated with stronger functional outcomes at 3 months postoperatively compared to home-based rehabilitation.^86,195 Since the 2020 CPG, a moderate-quality study compared a home-based program with more visits to outpatient physical therapy with generally fewer visits and found equivalent outcomes at 5 months postoperatively.¹⁹⁴ However, variability in the number of visits provided and the unclear role of the rehabilitation assistant (not a licensed physical therapist) in carrying out the home-based intervention reduce the certainty of these results.

Group versus individual physical therapy

Two moderate-quality studies have been added to the literature since the original 2020 CPG. One study found that group-based exercise plus usual care is superior to usual care alone in improving function 1 year postoperatively; this study did not directly compare group-based care to 1:1 care.²⁰⁸ Another study found that group-based physical therapy was superior to 1:1 physical therapy at 3 and 6 months postoperatively, but there are significant concerns about the lack of adherence data, the specific content of the interventions provided to each group, and considerable differences in the treatments received between groups.²⁰⁷

Digital health tools

Digital health encompasses the use of digital tools, including telehealth/telerehabilitation, smartphone applications, wearable sensors, remote patient monitoring, and other emerging technologies. Since the initial CPG was published, 3 high-quality studies compared various hybrid, remotely delivered, or technology-based interventions to usual care or usual rehabilitation.^128,189,210 They found that video-based exercise and education was superior in improving lower extremity strength and function compared to usual care, that telehealth-delivered self-management education resulted in short-term gains in step count, and that the addition of virtual reality to standard rehabilitation may improve lower extremity stability.^128,189,210 Additional moderate-quality trials have compared a variety of physical therapist-delivered telerehabilitation interventions, remote therapeutic monitoring approaches, and smartphone apps to various control and usual care conditions.^{38,117,129,154,174,202,211–229} Most commonly, they have found similar outcomes between telerehabilitation and in-person approaches. Often, studies have found that the addition of smartphone apps or remote monitoring technology as a supplement to standard rehabilitation results in short-term improvements compared to standard rehabilitation without the addition of apps or remote monitoring. One moderate-quality study showed lasting benefits to an app, fitness tracker with activity goals, and online health coaching for at least 1 year after TKA; otherwise, there is limited evidence to make a conclusion regarding the long-term impacts of these approaches.²¹⁴ Unfortunately, despite the great growth in evidence on digital health tools in the past few years, the differences in which tools are used, how they are used, and when they are used make it difficult to provide specific recommendations regarding how best to implement them with patients after TKA.

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• Approaches that include supervised physical therapist management that is individualized to each patient on the basis of their unique needs may produce better outcomes than group-based approaches or those offering less supervision from a physical therapist.

• Group-based therapy may be less costly than individual-based therapy.

• Remote therapeutic monitoring and/or telerehabilitation approaches may allow for frequent physical therapist supervision without concern for transportation barriers.

Risks, harms, and costs

• There were no reported risks or harms associated with providing supervised physical therapist care. Group therapy may fail to provide enough progression of interventions for more advanced patients or provide adequate engagement for patients with significant impairments. Therefore, group-based physical therapist management after TKA will require careful selection of patients, and patients’ progress should be monitored throughout their course of care.

• Telerehabilitation and other technology-based approaches to treatment may save the patient money in transportation and parking, and may either be cost-saving (due to needing less physical clinic space) or cost-producing (due to needing specialized technology) depending upon the specific technologies used.

Benefit–harm assessment

• There is a preponderance of benefit that supervised physical therapist management (in group-based or individual-based sessions) should be provided after TKA to address impairments and functional limitations.

Feasibility

• Feasibility of implementing telerehabilitation, remote therapeutic monitoring, or other technology-based delivery modes may vary on the basis of clinical setting and available technology.

• Feasibility of providing 1:1 versus group-based care may vary on the basis of clinical setting, space and time considerations, and/or insurance and payment restrictions.

Role of patient preferences

• Physical therapists should confer with each patient about their preferences regarding postoperative care settings and supervision, desire for 1:1 or group-based environments, and preferences for digital health tools. Out-of-pocket costs, transportation, and other potential barriers and facilitators to accessing care should be discussed.

Exclusions

• Exclusions for telerehabilitation as an alternative to in-person physical therapy include when a patient indicates a preference for purely in-person care, when the clinician is not trained in using digital health tools, or when the patient’s presentation precludes the safe delivery of telerehabilitation services.

Future research

• While truly withholding physical therapy after TKA may not be ethical, studies that compare supervised physical therapy with true nonactive control or self-directed exercise without physical therapist input are needed.

• Studies are also needed that compare individual versus group-based approaches where the content and dosage of the interventions are substantially similar between groups being compared.

• Future prognostic studies should also work to identify patient characteristics associated with successful self-management of functional recovery after TKA versus characteristics associated with requiring more intensive or frequent supervision from a physical therapist postoperatively to achieve desired functional outcomes.

• With the recent explosion in telerehabilitation, remote monitoring, and various smartphone apps used in rehabilitation, future research is needed to understand the impact of these technologies on patient care and how they are best used to support functional recovery after TKA.

Accelerated postoperative rehabilitation protocols

In patients with osteoarthritis of the knee selected for TKA, is an accelerated postoperative rehabilitation protocol associated with improved outcomes, as compared to traditional postoperative rehabilitation?

Physical therapy, including early mobilization, should start within 24 h of surgery for patients who have undergone TKA

Evidence Quality: moderate.

Recommendation Strength: moderate ♦♦♦◊.

Action statement profile

Aggregate Evidence Quality: 3 moderate-quality studies^230–232 and 9 low-quality studies.^233–241

Rationale

Four moderate-quality studies examined postoperative timing for receiving physical therapist management after TKA in an accelerated or “fast track” program and support the use of starting inpatient physical therapy earlier rather than later in hospital settings.^230–232 In each of these studies, physical therapy was initiated within 24 h of surgery and compared to a group that began therapy on or after postoperative day 1. Those that began physical therapy within 24 h had less pain and improved ROM. In 1 study, the accelerated group demonstrated improved function and fewer adverse events at 4 weeks and at 3 months.²³¹ Several low-quality studies compared a rapid recovery type of program with traditional care and found improved performance with walking distance at 4 weeks and score on a Timed Up and Go Test at 7 days.^233,234,237 In the multiple moderate- and low-quality studies, length of hospital stay favored an accelerated protocol over a standard protocol^{230–234,239–241} Two low-quality studies examined adverse events in accelerated postoperative rehabilitation versus a standard protocol. They found that accelerated rehabilitation programs were associated with lower incidence of deep vein thrombosis, pulmonary embolism, and pulmonary infection in the accelerated groups but higher incidence of hematomas and nausea.^239,240

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• Shortened/no inpatient hospital stay.

• Reduced pain.

• Improved physical function.

• Decreased risk of deep vein thrombosis, pulmonary embolism, and pulmonary infection.

Risks, harms, and costs

• Harms may include a higher risk of hematoma and nausea.

Benefit-harm assessment

• There is a preponderance of evidence that supports early mobilization after uncomplicated TKA.

Feasibility

• The implementation of early mobilization within 24 h of surgery and prior to discharge is feasible and does not require any additional resources or training.

Role of patient preferences

• Patient support at home is a consideration for an accelerated program, as participation in such a program is likely to impact inpatient length of stay or facilitate direct discharge to home postoperatively.

Exclusions

• None were identified.

Future research

• As evolving management emphasizes shorter lengths of hospital stays, including discharge within 24 h after surgery and surgery on an outpatient basis for some patients, additional high-quality research is needed to investigate the optimal timing and settings of TKA rehabilitation for patients in these management models.

Postoperative care settings

In patients with osteoarthritis of the knee selected for TKA, which postoperative care settings and/or setting transitions are associated with improved postoperative outcomes?

When possible, postoperative physical therapy after TKA may take place in an outpatient setting rather than in inpatient rehabilitation or at home

Evidence Quality: low.

Recommendation Strength: weak ♦♦◊◊.

Action statement profile

Aggregate Evidence Quality: 5 low-quality studies.^{129,238,240,242,243}

Rationale

Five low-quality studies suggest that patients should receive postoperative care in an outpatient setting rather than home health or inpatient rehabilitation.^{129,238,240,242,243} One study showed that patients who went directly to outpatient physical therapy following surgery had better function at 1 month postoperatively than patients who had 2 weeks of home health physical therapy before going to outpatient physical therapy.¹²⁹ Function at 2 years postoperatively was better in patients who were discharged directly to outpatient physical therapy than patients who underwent inpatient rehabilitation.²⁴² There are conflicting findings for function at 6 months: 1 study reported that outpatient physical therapy was favored over inpatient rehabilitation in terms of pain, function, and quality of life, whereas Rak et al found that patients who had rehabilitation in an inpatient setting had higher function than those who went directly to outpatient physical therapy after TKA.^238,242 A fourth study reported no difference in outcomes when patients were discharged to outpatient physical therapy versus inpatient rehabilitation.²⁴⁰ Differences in these reported outcomes were statistically significant but of little clinical difference. There were no differences between treatment settings when adverse events such as need for manipulation, deep venous thrombosis or pulmonary embolism, infection, or need for revision were compared.

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• There is a decreased risk of hospital-acquired infection when patients attend physical therapy in an outpatient setting.

• Some patients may feel more comfortable being discharged directly to home instead of staying at an inpatient facility; similarly, directly moving to outpatient physical therapy may allow patients increased interaction with the community.

• Patients managed in outpatient physical therapy may also experience improved pain and functional outcomes.

Risks, harms, and costs

• It is likely more cost-effective to manage patients in an outpatient setting compared to home health and/or inpatient rehabilitation.

• There was no difference in adverse events in the studies reported. However, it is possible that receiving care in an outpatient setting could result in increased risk of health complications for patients who are not good candidates, particularly those who have limited social support. The most important considerations would be concern for cardiopulmonary or thromboembolic events which would require intervention and/or readmission, postoperative wound problems, increased need for reoperation, and or/falls. Patients may also have increased rates of return to the emergency department or hospital re-admission.

Benefit–harm assessment

• Patients may experience improved function and pain scores when physical therapy services are provided on an outpatient basis. Outpatient physical therapy is more cost-effective than inpatient or home-health physical therapy. The studies supporting this recommendation did not report adverse events for patients undergoing physical therapy in an outpatient setting, but health complications and other adverse events, such as falls, are possible. The evidence supporting this recommendation is of low quality and is conflicting, making this recommendation weak. Therefore, physical therapists, patients, and other health care providers on the team should collaborate in a shared decision-making process regarding the ideal postoperative rehabilitation care setting for each patient.

Feasibility

• Patients must have adequate support to safely live at home and must have transportation to outpatient physical therapy.

Role of patient preferences

• Patient preferences should be considered within reason regarding best postoperative rehabilitation setting.

Exclusions

• The patient’s home safety, social support, and medical stability should be considered during preoperative and postoperative planning.

Future research

• Future research is needed to determine which patients are best candidates for outpatient rehabilitation.

• It is imperative to better understand which patients are most at risk for readmission/hospitalization and emergency room visits.

• Research regarding optimal postoperative care settings among patients receiving same-day or outpatient TKA (being discharged to home on the same day of surgery) is lacking.

• Higher-quality studies comparing long-term outcomes in individuals who had postoperative physical therapy in different settings should be conducted to strengthen this recommendation.

Postoperative care coordination protocols

For patients with osteoarthritis of the knee selected for TKA, which postoperative care coordination protocols are associated with improved outcomes?

In the absence of sufficient information, it is the opinion of this work group that physical therapists should collaborate in pre- and postoperative care coordination within an interdisciplinary team to optimize outcomes in patients undergoing TKA

Quality of Evidence: insufficient.

Recommendation Strength: consensus ♦◊◊◊.

List of included articles: No studies were identified that directly evaluate the effectiveness of care coordination protocols implemented or driven primarily by a physical therapist. For this reason, the work group elected to include information from studies addressing care coordination protocols available to patients before or after TKA procedures.

Rationale

Ho et al found that an integrated education program led to improved patient outcomes at both 3 days and 3 months postoperatively compared to a control group.²⁴⁴ The integrated education program involved multiple interventions delivered across the continuum of care, from preoperative education through postoperative follow-up. Notably, the intervention included general “prehabilitation education” provided by a nurse and incorporated a physical therapist as part of a multidisciplinary group education session—highlighting the value of physical therapy involvement in preoperative patient preparation.

Singh et al evaluated a formal same-day discharge program that included a preoperative one-on-one physical therapy visit and found no significant improvement in patient outcomes compared to a standard same-day discharge protocol.²⁴⁵ However, the study retrospectively compared outcomes among patients who successfully achieved same-day discharge and did not assess the impact of care coordination protocols on those requiring a longer hospital stay. Furthermore, the control group also received care involving “standardized protocols for all aspects of perioperative care and postoperative rehabilitation,” highlighting the consistent role of physical therapy in both groups.

Smith et al demonstrated the importance of the role of physical therapy in discharge planning from the acute care setting.²⁴⁶ Patients were more likely to be readmitted when the therapist’s recommendations were not implemented or when recommended follow-up services were not provided. Falvey et al identified strategies to expand physical therapy involvement in care coordination to reduce risk of readmission.²⁴⁷

Many studies have demonstrated that the Activity Measure for Post-Acute Care “6-Clicks” Basic Mobility assessment—commonly used during acute care physical therapy evaluations—has strong predictive value for discharge disposition from acute care settings.^248–252 This predictive utility has been validated across a wide range of patient populations, including individuals undergoing TKA.^248–252 These findings support the value of incorporating physical therapy into interdisciplinary discharge planning early in the postoperative period. Additionally, 2 of these studies explored the use of discharge disposition tools administered preoperatively, finding that their predictions aligned with Activity Measure for Post-Acute Care assessments—suggesting that both preoperative and postoperative variables play a key role in determining appropriate discharge destinations.^248,252,253 Taken together, these findings suggest that objective screening tools, used either pre- or postoperatively, could be considered to help guide discharge planning and support physical therapists in making recommendations.

A study by Wylde et al showed the Support and Treatment After Arthroplasty care pathway—an interdisciplinary intervention that includes physical therapy—was effective in improving pain outcomes in for patients experiencing chronic pain 3 months after TKA.²⁵⁴

Potential benefits, risks, harms, and costs of implementing this recommendation

Potential benefits

• Potential benefits include improved discharge planning, safe and well-coordinated transitions to home or post–acute care settings, informed recommendations for postoperative care, and optimized patient outcomes.

Risks, harms, and costs

• While there are no anticipated harms from including a physical therapist in care coordination, excluding them from the interdisciplinary team may result in overlooked mobility, functional, or rehabilitation needs, potentially contributing to suboptimal outcomes.

• Depending on the specific care coordination protocol, costs may vary significantly. Therefore, health care organizations should carefully consider both the costs and potential benefits of each approach to determine which strategy is most effective and sustainable within their particular setting.

Benefit–harm assessment

• Direct evidence evaluating the impact of physical therapist involvement in care coordination protocols is limited. However, consensus and available studies support including physical therapists in pre- and postoperative care coordination.

Feasibility

• The studies that demonstrated successful postoperative care required time, financial investment, and multiple health professionals. There is no single best practice due to variability. Instead, personalized, consistent follow- up care and standardized protocols can be considered.^5,6,254,255 Both approaches are feasible but require administrative support for resources, time, and personnel.

Role of patient preferences

• Patient preferences for discharge disposition and postoperative rehabilitation settings must be considered during shared decision-making regarding postoperative care coordination programs.

Exclusions

• None were identified.

Future research

• There is a need for more high-quality research and cost-effectiveness analyses that directly examine the effects of a physical therapy lead or developed care coordination protocols, implemented either pre- or postoperatively, on patient outcomes and other indicators such as length of stay, cost of care, patient satisfaction, complications.

Dissemination plans

The primary purpose of this CPG is to provide interested readers with full documentation of the best available evidence for various procedures associated with TKA. Publication of this guideline will be announced by press release and published in Physical Therapy, the journal of APTA.

Education and awareness about this CPG will be disseminated via online resources, such as webinars and continuing education courses, at professional annual meetings, and via social media.

Revision and reaffirmation plans

This CPG represents a cross-sectional view of current treatment and may become outdated as new evidence becomes available. It will be reviewed in 5 years and will be updated in accordance with new evidence, changing practice, rapidly emerging treatment options, and new technology; reaffirmed; or withdrawn. Future version may also add information regarding evaluation of patients post-TKA. This may include providing recommendations regarding the best tests and measures for evaluating impairments and functional limitations following TKA. Future versions may also provide recommendations regarding the optimal patient-reported and performance-based outcome measures to select with patients post-TKA to identify changes in impairments, activity limitations, and participation restrictions.

Disclaimer

This guideline is not intended to be a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. Clinical patients may not necessarily be the same as those found in a clinical trial. Patient care and treatment always should be based on a clinician’s independent medical judgment, given the individual patient’s clinical circumstances.

CRediT - Contributor roles

Allyn Bove (Conceptualization [Equal], Data curation [Equal], Investigation [Equal], Methodology [Equal], Project administration [Lead], Supervision [Equal], Validation [Equal], Visualization [Equal], Writing—original draft [Lead], Writing—review & editing [Lead]), Lindsay Carroll (Conceptualization [Equal], Formal analysis [Equal], Investigation [Equal], Methodology [Equal], Validation [Equal], Writing—original draft [Supporting], Writing—review & editing [Supporting]), Sean Cone (Conceptualization [Equal], Formal analysis [Equal], Investigation [Equal], Methodology [Equal], Validation [Equal], Writing—original draft [Supporting], Writing—review & editing [Supporting]), Pamela Dibblee (Conceptualization [Equal], Formal analysis [Equal], Investigation [Equal], Methodology [Equal], Validation [Equal], Writing—original draft [Supporting], Writing—review & editing [Supporting]), Craig Hensley (Conceptualization [Equal], Formal analysis [Equal], Investigation [Equal], Methodology [Equal], Validation [Equal], Writing—original draft [Supporting], Writing—review & editing [Supporting]), Kimberly Lenington (Conceptualization [Equal], Formal analysis [Equal], Investigation [Equal], Methodology [Equal], Validation [Equal], Writing—original draft [Supporting], Writing—review & editing [Supporting]), Paul Manner (Conceptualization [Equal], Formal analysis [Equal], Investigation [Equal], Methodology [Equal], Validation [Equal], Writing—original draft [Supporting], Writing—review & editing [Supporting]), David Scalzitti (Conceptualization [Equal], Formal analysis [Equal], Investigation [Equal], Methodology [Equal], Validation [Equal], Writing—original draft [Supporting], Writing—review & editing [Supporting]), James Tompkins (Conceptualization [Equal], Formal analysis [Equal], Investigation [Equal], Methodology [Equal], Validation [Equal], Writing—original draft [Supporting], Writing—review & editing [Supporting]), and Michael Bade (Conceptualization [Equal], Data curation [Equal], Investigation [Equal], Methodology [Equal], Project administration [Lead], Supervision [Equal], Validation [Equal], Visualization [Equal], Writing—original draft [Lead], Writing—review & editing [Lead])

Funding

This clinical practice guideline was funded exclusively by the American Physical Therapy Association, which received no funding from outside commercial sources to support the guideline’s development.

Role of the funding source

The views of the funding body have not influenced the content of the guideline.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

In accordance with APTA policy, all individuals whose names appear as authors of or contributors to this CPG filed a disclosure statement. All GDG members, APTA staff, and methodologists were free of financial conflicts of interest relevant to the topic under study. The GDG member with intellectual conflicts, due to authorship on articles included for review, abstained from authoring or voting on recommendations related to their evidence. Nonvoting GDG members Jeanine Kolman, PT, DPT, and Anita Bemis-Dougherty, PT, DPT, MAS, were employed by the American Physical Therapy Association during the development of this CPG.

Data availability

Supplementary materials contain data used for this clinical practice guideline. Additional data elements are available upon reasonable request from practice@apta.org.