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.

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.

Summer Camp a Success




Once again we had a fun and successful summer camp with a lot of youngsters showing great physical improvement and athletic development.  We also saw great progress in critical thinking and mental toughness in each participant.  We had 10 -15 kids all summer ranging in ages from 9 – 20 coming from Brophy Prep, St. Mary’s HS, Seton Catholic HS, Harvard, Stanford, Arcadia HS, Ingleside, and even one from the state of Virginia. Thanks to all our special guest coaches and lecturers (you can catch them on our Facebook page) which included former NFL players, coaches, college players, and CEO’s of major corporations. They gave great advice for sports, school and life.  Special thanks to Coach Chad and Coach Danny for helping out.

We have ongoing athletic development training throughout the year, and due to overwhelming demand we are going to try and arrange some more group class offerings.  We should also point out that NOW is the time to get ready for fall or spring sports, not 2 weeks before the season begins.  “Failing to prepare is preparing to fail”.  Same goes for recreational athletes getting ready for the skiing/snowboarding season or those getting ready for the Rock N’ Roll Marathon, or whatever.  We even have a group of guys that come in to train in preparation for the fall and winter hunting seasons.  We’re here to help!

T-Shirt Promotion


The new Rehab Plus T-shirts are in and everybody is trying to get their hands on them.  So how can you get yours?  Well they usually run $20.00, but for the month of August we are running a promotion for our PHYSICAL THERAPY clients.  From August 1 – August 31, if you attend 12 physical therapy visits, we will give you a T-shirt for FREE!!!  So in the month of August, if you attended 12 phyical therapy sessions, ask for your FREE T-shirt.

Also, for our loyal past clients and patients, if you refer a friend or family member to Rehab Plus and they become a patient, we will give you a T-shirt for FREE!!! Just make sure they mention your name in the “How did you here about us” section of the intake form. If you have any questions, please feel free to call us at (602) 954-7742.


We have always prided ourselves on giving patients the most comprehensive rehab protocol to return them to their activity of choice.  We are always “searching for a better mousetrap” and are continually working in-house on protocol development as well as scouring the clinical research data.  While we were developing the K.I.M. (Knee in Motion) device (reference archives for previous articles) we came up with an attachment for foot and ankle rehab called the “A.I.M.” or Ankle in Motion device.  It simply attaches to the machine and provides range of motion benefits previously very difficult to attain with manual therapy techniques.  Check out this cool video with Mitch Bruning, PT, taking Michael Humphreys through a program on the A.I.M.  Michael started as a true freshman on the Stanford basketball team this year and suffered a severe ankle sprain late in the season.  We have been getting tremendous range of motion outcomes on the A.I.M. machine.




In addition to the necessary modalities, soft tissue mobilization and manual therapy techniques are another critical component of foot and ankle rehab.  Here is another short video of Mitch performing manual therapy techniques on a patient.



Part 2 we’ll get to some of the exercise protocols we use to treat foot and ankle injuries.



Saying Goodbye to Our Spring Interns

Thanks to Our Spring Interns!

A big shout out to a great crew of interns we had for the spring semester.  Three of them will be completing their rotation this week.

Pictured Left to Right:

Savannah, Jen, and Olivia

Savannah and Jen have both now completed their physical therapy clinical rotations and will begin studying for their boards. Savannah will stay here in Phoenix and Jen is heading back to Northern Illinois University to take the Illinois boards.  Olivia will start applying to Physical Therapy schools and will graduate from ASU in May.  We didn’t get pictures, but thanks also to our other ASU interns George, Karly, Sarvin and Issac.