A Successful, Evidence-based Rehabilitation Protocol for a Total Knee Replacement

Total knee arthroplasty (TKA), commonly known as a total knee replacement, is a treatment approach to relieve the pain associated with end-stage knee osteoarthritis. Although a TKA successfully relieves the pain, there are major decreases in strength and function. Before the TKA surgery, it is common to have around a 36% decrease in quadriceps strength while, immediately post-surgery, the quadriceps strength decreases by 60% compared to age and gender matched individuals. Even more striking is that these strength deficits extend to 6 months post-operation. Clearly, TKA rehabilitation needed a different approach due to the lack of effectiveness in restoring muscle strength. In 2002, the National Institutes of Health recognized TKA rehabilitation as one of the most understudied areas in physical therapy. A few years later some evaluation studies were done and physical therapy was shown to be ineffective in producing long-term benefits for those with TKA’s. This launched a revolution that provided many new approaches to TKA rehabilitation, of which the most effective is described here and utilized by Rehab Plus.
The quadriceps muscle group is the most affected area with the greatest strength losses occurring within the first month. Due to this critical window, gaining back quadriceps muscle strength is essential and the primary goal during rehabilitation. A major way to reduce these strength decreases is through neuromuscular electrical stimulation (NMES). Rehabilitation programs that utilized NMES were extremely successful up until around 6 weeks with the greatest improvements seen around weeks 3-4. The benefits of NMES are clearly seen when looking at long term studies that give only half their subjects electrical stimulation. Both groups receive traditional physical therapy, but the group that additionally receives NMES has significantly greater improvements that even extend to one year. A key point is that the subjects who achieve the highest electrical stimulation have the greatest improvements. It is essential that the patient try and achieve the highest volitional stimulation to experience the best results.
With NMES being a major component of successful TKA rehabilitation, the second and final component was revolutionary. As mentioned earlier, a few years ago physical therapy practices for TKA were shown to be ineffective. Most clinics during that time were using lower intensity resistance training. This is most likely the cause for the lack of long-term benefits which promoted the use of higher intensity training for TKA’s. Since deficits in muscular strength are seen, it makes sense that higher intensity protocols, which elicit greater strength gains, lead to greater improvements. Successful high intensity protocols involved progressively overloading all major muscle groups of the legs with a 3-4 sets of 10 repetitions at 75% of one repetition maximum general outline. The concept of progressive overload is noteworthy here because, clearly, one could not start at a high intensity right after surgery. Rather, a lower intensity utilizing resistance bands or ankle weights are used early on with resistances increased over time as muscle fatigue no longer occurs. Integrated within the high intensity training are exercises that function to increase range of motion. Compared to rehab patients that don’t receive higher intensity training, utilization of intense protocols leads to greater improvements that extend even to one year. One concern with more intense training may be an increased risk of injury. However, this has not been reported in studies utilizing these protocols. As long as a professional physical therapist or trainer is emphasizing proper form, the risk of injury decreases. The usage of higher intensity training has allowed modern physical therapy practice to have a major and lasting impact on TKA’s and even has the potential to restore function back to normal levels.

Bade, M.J., & Stevens-Lapsley, J.E. (2012). Restoration of physical function in patients following total knee arthroplasty: an update on rehabilitation practices. Current Opinion in Rheumatology, 24(2), 208 – 214.

Minns Lowe, C.J., Barker, K.L., & Dewey, M. (2007). Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematice review and meta-analysis of randomized controlled trails. British Medical Journal, 335, 812.

Power Plate Hamstring ROM for Runners


As part of our internship curricullum, we like to have our students write up a piece on a subject that interests them in the confines of their internship. James Armstrong, ASU student, wrote this piece about Whole Body Vibration via the Power Plate, a rehabilitation tool we’ve found very valuable at Rehab Plus.  Thanks to Jo Dibuz, University of Illinois-Chicago Physical Therapy Clinical Rotation Intern for the video demonstration.

The Power Plate is continuously producing positive outcomes for all types of people, whether an athlete training or a patient going through rehabilitation protocols. The Power Plate machine provides what is called whole-body vibration (WBV), which is designed to decrease muscle soreness, increase circulation, increase muscular power and strength and even promote better range of motion. The Power Plate accomplishes this by emitting vibrations throughout the body at different frequencies, rest intervals, and amplitudes in order to promote the body to recruit more muscle fibers, thus training more muscle fibers than traditional training. By offering the wide variety of settings, The Power Plate is able to offer the greatest performance outcomes to a wide variety of users. Rehab Plus recognizes The Power Plate as a top-tier rehabilitation and performance machine, and are able to offer these benefits to produce astounding outcomes.

Call today to schedule an evaluation for injury assessment, biomechanic analysis, or just to find out more cool stuff on the Power Plate (602) 954-7742.

First Session of Summer Camp Complete/Second Sessions Starts July 5th

The first half of our summer camp has been a lot of fun with a lot of coaching, learning, and production! We are completely full of participants as we wrap up the first session this week. Special thanks to Mike Walker for assisting us in the camp. Also special thanks to our guest speakers Rob Fredrickson, Rudy Carpenter, and Ryan Kealy. We also received great leadership from our senior member Luke Zuluaga. Luke has been working with us every summer since he was in middle school and he is now off to the Air Force Academy to play football, run track, and become an achieving cadet! Check out Luke’s tape HERE from the Arizona State High School Track and Field Championships. This tape went viral, made USA Today! Luke can run! This year we opened the camp up to some younger athletes and they really stayed focused and learned by watching and paying attention to detail. Looking forward to starting the second half of our camp next week!

Every athlete has improved dramatically and we are proud of all our ahtletes and the gains they have made.  If you have a son or daughter and are interested in seeing them improve athletically, please give us a call at (602) 954-7742 to register.  Click here for more information.

BCBS of Arizona Changes

Since our original newsletter a couple weeks ago alerting our friends and patients to the changes in Blue Cross/Blue Shield for 2016, we have been inundated with people contacting us with really good questions, and really good information. We are only trying to help everyone understand the changes taking place, and being able to make an informed, educated decision regarding one’s healthcare. Rest assured, we have reached out to people we know in both the benefits side of health insurance as well as administrators trying to get as much information as we can. IF you purchased a Blue Cross/Blue Shield PPO individual plan more than 5 years ago, you are grandfathered into the plan and may continue to see the healthcare providers OF YOUR CHOICE if you choose to maintain your present. IF you choose to join the “narrow network” i.e. Alliance Network or Select Network plans, you can only see the healthcare providers inside the hospital system,of which Rehab Plus will not participate. We would suggest you check with your physicians and healthcare providers to make sure they are contracted with whatever health plan you choose. We will continue to research this area and will continue to keep you updated. If you have any questions, feel free to contact us.

Rehab Plus, Inc.

Motion is the Best Lotion

This is one of our favorite sayings at Rehab Plus.  In essence, the bulk of what we do in physical therapy is based on movement: be it restoration of range of motion after an injury, teaching/coaching/cueing correct movement patterns (be it walking, running, throwing, etc.), understanding balance and functional transfer of weight, we could go on an on.

We pride ourselves on being at the forefront of teaching MOVEMENT.  Be it a  neuro patient learning to walk again to a prospective NFL draft pick learning how to run the fastest 40 yard dash he is capable of, to everything in between, teaching proper MOVEMENT is one of our specialties.

The following piece is a little technical, but we found it pretty cool.  It’s about a boxer called “Chocalatito”(considered one of the best pound for pound boxers in the world) and his use of proper footwork and balance to maximize his boxing efficiency.  The piece is called “The Art of Moving”.  Hope you enjoy it.

Thanks to All Our Fall Interns

Much thanks to all of our fall interns.  They’ve done a great job! Javier, Arielle and Sam will be graduating from ASU and probably going to physical therapy school. Mariola will be heading back to Chicago to finish up the last part of her physical therapy program at the University of Illinois-Chicago. We’ll miss them all!

BMX Legend Eddy King Fights to Walk Again

On October 6, 2013, BMX legend, Eddy King suffered a traumatic spinal cord injury after falling off his bike.  On his 2 year anniversary of his accident, we wanted to give an update on Eddy’s amazing recovery and journey to walking without wheelchairs or canes.   Please watch the video.

With spinal cord injuries there is no definite recovery or outcome.  Eddy has proven that the body can and will heal.  Function can be regained through hard work and dedication.  As Eddy says “there is no blue print for recovery from a spinal cord injury”.

Eddy’s trainer, Chad Dunn, says “we have taken an athletic approach to Eddy’s rehabilitation, incorporating training movements, not single muscles.  We always say around here, ‘It’s not where you start, but where you finish’, and Eddy is a great testimomy to that”.

Technology in Physical Therapy and Sports Performance



The world is certainly a different place now than it was a year or two ago, much less ten years ago.  Technology has become an increasing part of our every day lives and some aspect of technology touches everything we encounter.  Keeping up with technology and implenting it into one’s business effectively is a challenge for all, Rehab Plus included.  Following is a pretty cool article we found about how the St. Louis Rams are embracing technology to more effectively teach and connect with a very young team made up mostly of “millenials”.




Here are just a couple of examples of how we’re using some elements of technology to deliver better care:


  1. Home Exercise Programs-  No need to draw stick figures of exercises, or hand out some “boiler plate” home exercise program.  In many cases, we have started to video patients performing selected home exercises, then text or email to them.  This way the patient gets visual “real time” feedback, the sets and reps are verbally spoken, the proper technique is “cued”, demonstrated, and corrected,  and all they have to do is go to their smart phone and it’s right in front of them.
  1. “Coaches Eye”- This is a great app that allows us to tape, then analyze mechanical efficiency (i.e gait correction, postural correction, etc.) and then text or email to the patient so they can study themselves.  For “visual” learners this is a great teaching tool.  And it’s a free download app.  We have used this app extensively with athletic performance as well as clinical physical therapy.
  1. Digital Correspondence-  As simple as it sounds, once we have patients in our system, the ability to text or email personally and privately with the patient can be a very time effective tool.