cations for this procedure include middle-aged patient with isolat- ed patellofemoral OA with significant pain and functional disability (Hussain et al., 2016). Contraindications to this procedure include inflammatory arthritis, crystal arthropathy, severe patellar maltrack- ing, tibiofemoral arthritis, and high activity levels (Lonner, 2007). Lastly, a total knee replacement is reserved for those patients with end-stage arthritis as a final option (Hussain et al.) Patients with end-stage knee OA most likely experience severe pain, disability, and joint deformity; a TKA would be the only effective treatment for these individuals (Nielsen et al., 2017). A study by Weinstein and colleagues (2013) estimated that ap- proximately 52% of adults diagnosed with symptomatic knee OA in the United States will undergo a TKA. Once a patient gets to the point of severe knee OA and has significant impairment and functional limitations, the most effective way to reduce pain and disability is to undergo a TKA. A patient will undergo the previous stated examination process to determine the amount of knee OA in the joint. by Jakobsen and colleagues (2014), followed a group of patients following a total knee replacement during a seven-week physi- cal rehabilitation program with and without progressive strength training. Following a total knee replacement, there is generally loss of muscle strength and functional performance in the early phase of postoperative recovery. The study found no statistically significant or clinically meaningful differences between the two intervention groups. In both groups, the self-reported function and quality of life outcomes scores were higher following eight weeks of postoperative care when compared to the outcomes performed before surgery. This study used a maximum walking distance in six-minute tests, and there were no significant dif- ferences between groups following seven weeks of supervised physical therapy with or without progressive strength training two times per week. Knee extension strength in neither group reached the level recorded before surgery. A systematic review by Pozzi and colleagues (2013) looked at a variety of interventions and clinical settings that could be used for postoperative total knee replacement patients and examined the outcomes associated with these varying aspects of postop- erative care. Although the Jakobsen and colleagues study (2014) regarding progressive strengthening following a total knee re- placement found no significant differences between groups that included and did not include this type of exercise, Petterson and colleagues (2009) did find better outcomes when using a progres- sive strengthening protocol. Petterson and colleagues (2009) found that a progressive strength- ening protocol (with or without NMES) following a TKA resulted in significantly better outcomes 12 months following surgery in regards to quadriceps strength, Timed Up and Go, and stair climbing test times, and distance walked in the 6-Minute Walk Test when compared to those patients who received standard re - habilitation that focused on functional training. Another study by Moffet and colleagues (2004) showed better Western Ontario and McMaster Universities Osteoarthritis Index Score (WOMAC) and higher 6-Minute Walk Test distances one year following a TKA. The study included patients participating in a program that used a protocol that included motor learning and training-specificity principles called intensive functional rehabilita- tion . This protocol included a warm-up, specific strengthening ex- ercises, functional task-oriented exercises, endurance exercises, and a cool-down period. Aquatic therapy can be used for patients following a total knee replacement once the incision is healed and there is no risk of infection. Water-based rehabilitation protocols are often thought to reduce stress on the joint and allow an individual to strengthen the lower extremities by using the resistance of the water and taking advantage of the buoyancy of the water, which helps to reduce the weight of the body. There are advantages of aquatic therapy during the early stages of rehabilitation when the inci-
are shorter surgical time, less blood loss, quicker rehabilitation, and better range of motion (Hussain et al.). It is also important to note that a unicompartmental knee arthroplasty can be revised into a TKA down the road if arthritis develops on the other side of the joint. For a younger patient who has only medial or lateral com- partment knee OA, this may be a good option because of quicker recovery time, better range of motion, and less surgical risk with the option of a TKA being available down the road if needed. A patient with isolated patellofemoral arthritis may be treated surgically in a variety of ways: ● Arthroscopic debridement with or without lateral release. ● An unloading tibial tubercle osteotomy. ● Patellofemoral arthroplasty. ● Total knee replacement. ● A patellectomy (rarely) Hussain (Hussain et al., 2016). A patellofemoral arthroplasty may be used in younger patients who are not suffering from tricompartmental joint arthritis. A patellofem- oral arthroplasty is a less aggressive treatment approach. The indi- Rehabilitation following a total knee replacement Following a total knee replacement, physical and occupational therapy are generally performed in order to return the patient to optimal functional level. Patients can attend preop physical therapy or educational seminars to learn basic exercises to perform before surgery to increase strength and mobility, which may lead to better postoperative outcomes. A patient can also attend preoperative training in order to understand postsurgical protocols and under- stand what to expect following surgery. A patient admitted to the hospital following surgery will generally have physical and occupational therapy during her stay. The goals of physical and occupational therapy following a total knee re- placement, as with any surgery, are to improve function, improve mobilization, and achieve functional goals related to discharging the patient. The patient may then be discharged to her home with home health services or to a rehabilitation facility or may be- gin outpatient physical therapy shortly after returning home. The patient will then continue with physical or occupational therapy if needed. The goals of home health physical therapy are to make sure the patient is safe around his home and to achieve functional goals in the home setting while improving mobility and beginning basic strengthening activities. Once the patient achieves enough func- tional mobility to travel outside the home, he will start outpatient physical therapy, which is typically a more aggressive protocol than home health physical therapy. Patients in a rehabilitation fa- cility also aim to improve mobility and function in order to be dis- charged home and then will either require home health physical therapy or be progressed to outpatient physical therapy, depend- ing on their needs. Patients may also be discharged home and immediately start out- patient physical therapy if the physician decides this is the best plan. The goals of outpatient physical therapy aim to further re- turn the patient to optimal functional level while restoring strength, range of motion, flexibility, and balance, and improving gait. It is well known that physical therapy following a total knee replace- ment is required; however, there is limited information regarding the best mode and duration or frequency of intervention required to achieve maximal benefits. A study by Artz and colleagues (2015) aimed to evaluate the ef- fectiveness of postdischarge physical therapy exercise in patients with primary total knee replacements. This was a systematic re- view and meta-analysis of studies looking at the effects of exer- cise on patients following a total knee replacement. This study concluded that there are short-term benefits of physical therapy and exercise in a patient’s functional ability, but did not find long- term benefits. Further research in the area of long-term benefits of physical therapy following a total knee replacement is needed. Another study looked at physical therapy programs following a total knee replacement with or without progressive strength train- ing and the effects on functional outcomes. This study, performed
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