Independent Exercise Compared With Formal Rehabilitation Following Primary Total Knee Replacement

We will randomize patients who are scheduled to have primary total knee arthroplasty to
receive either a prescription for formal physical therapy (PT) or instructions for
independent exercises. Inclusion criteria will be: scheduled for primary total knee
arthroplasty, an age of eighteen years or older, speak English, and have a computer with
access to the Internet. Exclusion criteria will be: any knee arthroplasty other than total
knee, patients not planning to return for follow up care, patients relying on others for
basic functioning, do not speak English, and do not have a computer with access to the
Internet. Enrollment will occur at the initial clinic visit in the surgeon's office.

Informed consent will be received from patients who will participate in the study at the
initial clinic visit and these patients will be randomized equally to either the PT/OT or
independent exercise cohort using the REDCap website randomization feature. REDCap is a
secure, web-based application for building and managing online surveys and databases that
will be utilized for this study for data management. Patients that will be randomized to PT
cohort will be prescribed formal therapy for twelve weeks with supervised exercises to
regain knee strength and range of motion. Therapists will not be involved in the study
design and therapists will not be informed that patients are participating in this study.
The content, frequency, and duration of the rehabilitation program will be at the discretion
of the treating therapist, consistent with usual practice.

The patients who will be in the independent exercises cohort will be registered on
www.careforpatients.com, an online rehabilitation resource that provides computer aided
rehabilitative exercises. Patients will follow a prepared 12-week protocol of exercises to
perform postoperatively to gradually regain their knee strength and range of motion.

Post-operative weeks 0 - 1, the patients will perform three sets of ten repetitions everyday
of: supine ankle pumps, supine heel slides, seated quad sets, supine glut sets, and supine
hip abduction/adduction. The patient will also perform three sets of patella mobilization
for one minute each and three sets of one repetition of supine knee extension.

Post-operative weeks 1 - 2, the patients will perform three sets of ten repetitions everyday
of: supine heel slides, prone knee flexion, supine knee extension, supine SLR flexion,
sidelying SLR abduction, prone SLR extension, sidelying SLR adduction. The patient will also
perform three sets of patella mobilization for one minute each and three sets of one
repetition of supine knee extension with weight.

Post-operative weeks 2 - 4, the patients will perform three sets of ten repetitions everyday
of: standing knee extension, standing knee flexion, standing SLR flexion, standing SLR
abduction, standing SLR extension, standing SLR adduction. The patient will also perform
three sets of patella mobilization for one minute each, three sets of sitting hamstring
stretch for thirty seconds each, prone quad stretch for thirty seconds each, and three sets
of single leg stance for thirty seconds each.

Post-operative weeks 4 - 8, the patients will perform three sets of ten repetitions everyday
of: bilateral mini squats, standing SLR flexion, standing SLR abduction, standing SLR
extension, standing SLR adduction. The patient will also perform three sets of sitting
hamstring stretch for thirty seconds each and prone quad stretch for thirty seconds each.

Post-operative weeks 8 - 12, the patients will perform three sets of ten repetitions
everyday of: bilateral wall squats, forward step-ups, and side step-ups. The patient will
also perform three sets of sitting hamstring stretch for thirty seconds each and prone quad
stretch for thirty seconds each. Patients will be advised to perform these exercises as
often as possible, but at least once a day.

All patients will have regularly scheduled follow-up visits per usual practice at six-weeks
post-operatively, six-months post-operatively, and 12-months post-operatively where a
physical exam will be performed to check the range of motion of the knee, gait, and lower
leg muscle strength.

The primary outcome of the trial will be to evaluate the efficacy of formal therapy compared
with independent exercises at twelve months after surgery with use of the American Knee
Society (AKS) Knee Score. Secondary outcomes will include the Knee and Osteoarthritis
Outcome Score (KOOS) the measurement of health status with use of the Short Form-12v2
(SF-12v2) and activity level with the University of California, Los Angeles (UCLA) Activity
Score.

At enrollment, a baseline evaluation will be conducted to capture demographics, height,
weight, primary diagnosis, medical comorbidities, and social supports as well as completion
of the selected outcome measures, AKS, KOOS, SF-12v2, and UCLA Activity Score. At the
twelve-week, six-month and twelve-month follow-up visits, the study subjects will complete
the AKS, KOOS, SF-12v2, and UCLA Activity Score questionnaires during their clinic visit or
will be contacted by telephone or mail to complete the questionnaires if they do not have
appointments for twelve-week, six-month or twelve-month follow-ups.

Inclusion Criteria:

- scheduled for primary total knee arthroplasty

- an age of eighteen years or older

- English speaking

- have a computer with access to the Internet

Exclusion Criteria:

- any knee arthroplasty other than total knee

- patients not planning to return for follow up care

- patients relying on others for basic functioning

- do not speak English

- do not have a computer with access to the Internet

- prior physical therapy