© 2023 THE AUTHORS European Journal of Physical and Rehabilitation Medicine 2024 February;60(1):74-83

Open access at https://www.minervamedica.it DOI: 10.23736/S1973-9087.23.07899-1

ORIGINAL ARTICLE

Enhanced recovery after surgery combined with quantitative

rehabilitation training in early rehabilitation after total
knee replacement: a randomized controlled trial
Songsong JIAO 1, Zhencheng FENG 1, Jian HUANG 2, Tianming DAI 3, Ruijia LIU 4, Qingqi MENG 1 *

1Department of Orthopedics, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China; 2Department of Traumatic
Orthopedics, The Central Hospital of Xiaogan, Hubei, China; 3Guangzhou Institute of Traumatic Surgery, Guangzhou Red Cross
Hospital, Jinan University, Guangzhou, China; 4Department of Orthopedics, Fosun Chancheng Hospital of Foshan, Foshan, China
*Corresponding author: Qingqi Meng, Department of Orthopedics, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China.
E-mail:[email protected]

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ABSTRACT
BACKGROUND: The number of patients undergoing total knee replacement (TKR) is increasing yearly; however, there is still a relative lack
of specific, individualized, and standardized protocols for functional exercise after TKR. Quantitative rehabilitation training was developed to
improve the recovery of postoperative joint function, increase patient satisfaction, shorten the length of the hospital stay, improve the quality of
life, and promote rapid patient recovery.
AIM: We aimed to compare the effectiveness of quantitative rehabilitation training based on the enhanced recovery after surgery (ERAS) con-
cept with conventional rehabilitation training in the early rehabilitation of patients with TKR.
DESIGN: This was a single-centre, prospective, randomized controlled trial.
SETTING: Inpatient department.
POPULATION: Participants were patients who underwent unilateral total knee replacement.
METHODS: Based on the ERAS concept, a quantitative rehabilitation training program was developed for the quantitative group, and the
control group underwent conventional rehabilitation training. Seventy-eight patients undergoing TKR were randomly divided into two blinded
groups: the quantitative rehabilitation group and the conventional rehabilitation group. The analysis was performed according to per-protocol
practice. The primary outcome metric was the Hospital for Special Surgery Knee Score (HSS Score), and secondary outcomes included patient
satisfaction, Visual Analog Pain Score (VAS), time to get out of bed for the first time after surgery, 6-minute-walk test (6MWT), quality-of-life
score (SF-36), and number of days in the hospital. The incidence of postoperative complications was also recorded.
RESULTS: There was no significant difference in HSS scores between the two groups before surgery (P=0.967), but the quantitative rehabilita-
tion training group had significantly higher scores at two weeks (P=0.031), 3 months (P<0.01), and 12 months (P<0.01) after surgery than did
the conventional rehabilitation training group, and both groups had higher HSS scores than before surgery. The quantitative training group had
significantly higher VAS scores at 24 hours and three days postoperatively than the conventional training group (P<0.01), while there was no
statistical significance at any other time points. The quantitative rehabilitation group had an earlier time to get out of bed for the first time after
surgery (P<0.01), a longer 6MWT distance (P=0.028), and higher patient satisfaction and quality of life scores (SF-36) (P<0.01) that did the
control group. The number of days in the hospital was lower in the quantitative training group than in the control group (P<0.001). There was no
significant difference in the incidence of postoperative complications between the two groups.
CONCLUSIONS: Compared with conventional rehabilitation training, quantitative rehabilitation training based on the ERAS concept was
found to be safe and effective and can accelerate the recovery of joint function after surgery, shorten hospitalization time, improve patient satis-
faction, and promote rapid recovery.
CLINICAL REHABILITATION IMPACT: The quantitative rehabilitation training based on the ERAS concept provides a new program for re-
habilitation exercises after total knee arthroplasty, which is safe and reliable, accelerates the recovery of joint function, and should be considered
for clinical promotion.

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QUANTITATIVE REHABILITATION TRAINING AND RECOVERY FROM TKR JIAO

(Cite this article as: Jiao S, Feng Z, Huang J, Dai T, Liu R, Meng Q. Enhanced recovery after surgery combined with quantitative rehabilitation
training in early rehabilitation after total knee replacement: a randomized controlled trial. Eur J Phys Rehabil Med 2024;60:74-83. DOI: 10.23736/
S1973-9087.23.07899-1)
Key words: Enhanced recovery after surgery; Arthroplasty, replacement, knee; Randomized controlled trial.

O steoarthritis of the knee (KOA) is one of the most

common types of arthritis and has been a leading
cause of disability for many years.1, 2 Total knee replace-
Materials and methods
Trial design and participants
ment (TKR) is the most effective treatment of end-stage This double-blind, randomized controlled trial was con-
KOA. The annual TKR rate has recently increased from ducted in one hospital from April 2019 to May 2020. The
5% to 17% worldwide.3 clinical ethics committee of the authors’ hospital approved
Rehabilitation, including physical therapy, pedal-based the study (2019-086-01) and registered it on ClinicalTrials.
protocols, and continuous passive motion (CPM),4-7 is of- gov (ChiCTR1900023136). The study design and imple-
ten required after TKR, but the appropriate format remains mentation followed the Consolidated Standards of Report-
highly controversial. Loss of lower extremity strength and ing Trials (CONSORT) Statement guidelines. The diag-
function often occurs within one month after TKR,8 so nosis of KOA was based on the criteria of the American
early exercise plays an important role in functional recov- College of Rheumatology. The inclusion criteria were as
ery. Although previous studies reported that rehabilitation follows: 1) age >65 years; 2) diagnosis of end-stage KOA
for TKR was not correlated to the ultimate prognosis,9-11 and no hip or ankle disease; 3) first unilateral total knee
recent studies have found that progressive resistance train- arthroplasty; and 4) the patient voluntarily participated and
ing and functional strengthening exercises can improve signed an informed consent form. The exclusion criteria
knee function while ensuring safety.12, 13 Therefore, ad- were as follows: 1) patients who had undergone major sur-
equate functional exercise can stimulate muscle growth, gery within the past month; 2) patients with cognitive or
increase muscle strength, and improve recovery of joint mental disorders that prevent rehabilitation training; and 3)
function. However, to date, most rehabilitation programs patients with poor muscle strength of the muscles around
have been limited to preoperative or postoperative peri- the knee joint before surgery.
ods,14-16 and there is still a lack of specific, individualized,
and standardized programs for functional exercise in the Data availability statement
perioperative period of TKR. Quantitative rehabilitation is
a step-by-step optimization of previous studies to develop The data associated with the paper are not publicly avail-
progressive and phased training for patients throughout able but are available from the corresponding author on
the perioperative period.14, 15, 17, 18 reasonable request.
Since the concept of enhanced recovery after surgery Randomization and blinding
(ERAS) was introduced in 2001,19 it has gained wide
acceptance and application in the perioperative surgical Eligible patients were given information about the study
period. ERAS was implemented in general surgery with for at least one day to decide whether to participate. Ran-
positive results and then gradually applied to joint surgery. dom sequences were created by SAS 9.1 statistical soft-
Still, there are relatively few prospective studies compar- ware (SAS Institute) and placed in opaque sealed enve-
ing the clinical results of ERAS in TKR.20 lopes. The enrolled patients were randomly assigned to
Therefore, the purpose of this randomized controlled the quantitative and conventional rehabilitation training
trial was to evaluate the impact of quantitative rehabilita- groups in a 1:1 ratio, with block sizes of 4 and 6. Differ-
tion training based on the ERAS concept on the early re- ent personnel completed the random assignment sequence,
covery of patients after TKR. We hypothesized that quan- patient registration, and outcome assessment. The sur-
titative rehabilitation training based on the ERAS concept geons, outcome assessors, and data analysts were unaware
would be superior to conventional rehabilitation training of the grouping and implementation during the study. Pa-
in early postoperative recovery in patients undergoing tients were also unaware of the groupings and the training
TKR. performed in each group. The rehabilitation therapist only

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JIAO QUANTITATIVE REHABILITATION TRAINING AND RECOVERY FROM TKR

performed rehabilitation for the patient and did not inter- (22 points), mobility (18 points), muscle strength (10
fere by providing advice or analysis. points), flexion deformity (10 points), and stability (10
points). The maximum score is 100 points, and the higher
Interventions the score, the better the recovery of joint function.
The quantitative rehabilitation training program was car- VAS
ried out throughout the perioperative period. Preoperative
muscle strength training and postoperative functional ex- VAS scores were used preoperatively and 24 hours, three
ercise were divided into three phases, each with a gradual days, two weeks, three months, and 12 months postopera-
transition process. The first phase was muscle strength tively. The VAS uses a 10-cm line to assess the patient’s
training with passive rehabilitation training. The second pain by informing the patient that 0 means “no pain” and
phase shifted from passive rehabilitation training to active 10 means “severe pain” and asking the patient to draw a
rehabilitation training. The third stage was the transition line crossing the 10-cm line at a level that best reflected
from non-weight-bearing to weight-bearing training, with their pain level.
a gradual increase in standing and walking. The rehabili-
tation therapist explained and assessed the patient to en- Patient satisfaction
sure the rehabilitation plan was followed accurately. The On the day of the patient’s discharge and at three months
therapist explained or demonstrated in detail the content, and one year after surgery, patients were asked to rate
method, and duration of rehabilitation training and record- their satisfaction according to four options: very satisfied,
ed the amount of daily training on an assessment form. Any satisfied, neither satisfied nor unsatisfied, or unsatisfied.
adverse reactions were reported to the physician, who then Surveys were completed according to the patient’s actual
provided treatment or adjusted the rehabilitation program. condition.
The conventional rehabilitation training group was given
only conventional exercises, such as CPM, according to Six-Minute-Walk Test
the traditional method. The same rehabilitation therapist
The patient walked for 6 minutes at a speed as fast as pos-
explained the techniques of functional training to the pa-
sible. The patient walked back and forth along a 50-meter
tient but did not specify the frequency and intensity of each
corridor, and the distance traveled was measured. If need-
training modality, and did not interfere with the completion
ed, patients used a cane or stick to perform the test.
of the training.
Other measurements
Surgical procedure
A 36-item short form survey was used to assess the quali-
All operations were performed under general anesthesia
ty-of-life status of patients at 12 months after TKR. It in-
by surgeons with at least 5 years of TKR experience. The
cluded both physical health and mental health, with higher
procedure was performed in a standard fashion with an an-
scores indicating better health. The incidence of postop-
terior longitudinal midline approach for medial parapatel-
erative complications was recorded, and the changes of
lar arthroplasty. Femoral and tibial prostheses were fixed
inflammatory markers in both groups were also evaluated
with bone cement. A tourniquet was used during the pro-
after surgery.
cedure, and the average time was 45 minutes.
Sample size calculations
Outcome measurements
Sample size calculations were based on data from pre-
Study results were predetermined at the time of clinical vious studies,21 and we expected a difference of 85±4.1
enrollment and prior to trial initiation. between groups in the conventional rehabilitation group
Knee function score at 12 months. At α=0.05, the difference in HSS scores be-
tween the quantitative rehabilitation training group and the
The Hospital for Special Surgery (HSS)21 scoring system conventional rehabilitation training group at 12 months
was used to collect HSS knee scores from both groups be- postoperatively was tested at approximately 5.2. Allow-
fore surgery and two weeks, three months, and 12 months ing 20% of patients to miss follow-up evaluations, we ul-
after surgery to evaluate the functional recovery of the timately determined that at least 38 participants in each
knee joint. The score includes pain (30 points), function group would provide 80% of the power.

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QUANTITATIVE REHABILITATION TRAINING AND RECOVERY FROM TKR JIAO

Statistical analysis Table I.—Patient demographics and preoperative characteristics.

Characteristic QRT (N.=39) RRT (N.=39) P value
We used SPSS software (version 24.0; IBM) for all sta-
Age*(yr) 74.6±6.0 76.0±6.3 P=0.313†
tistical analyses. Continuous data were tested for normal Sex# P=0.215‡
distribution using the Shapiro-Wilk Test. Data that con- Male 13 (33.3) 9 (23.1)
formed to a normal distribution are expressed as mean and Female 26 (66.7) 30 (76.9)
standard deviation, and those that did not are expressed BMI*(kg/m2) 30.0±2.1 30.8±2.7 P=0.189†
ASA classification# P=0.720‡
as median and interquartile range. Data for categorical I 6 (15.4) 8 (20.5)
variables are expressed as frequencies and proportions. II 27 (69.2) 26 (66.7)
Continuous variables were analyzed using Student’s t-test III 6 (15.4) 5 (12.8)
and associated 95% confidence intervals and the Mann- Laterality# P=0.651‡
Right 18 (46.2) 20 (51.3)
Whitney U Test. Preoperative and postoperative changes Left 21 (53.8) 19 (48.7)
were analyzed using paired t-tests. The Chi-squared or *The values are given as the mean and the standard deviation; #data are presented
Fisher’s Exact Test was used to compare categorical vari- as the number (percentage) of patients; †Student’s t-test; ‡Pearson χ2.
ables. Multiple comparisons were performed using re-
peated measures Analysis of Variance and P values with
Bonferroni correction. Results
Patient demographics

Enrollment Assessed for eligibility (N.=179)

A total of 179 patients who underwent TKR between April
1, 2019, and May 1, 2020, underwent screening, and 78
Excluded (N.=88)
patients who completed follow-up and were analyzed
- Not meeting inclusion criteria were divided into quantitative and conventional rehabilita-
(N.=35) tion training groups (Figure 1). There was no significant
- Declined to participate (N.=53)
- Other reasons (N.=0) difference in the preoperative baseline characteristics be-
tween the two groups of patients (Table I). All patients
Randomized (N.=91) completed the 12-month postoperative follow-up, and the
patients did not experience any adverse effects during the
rehabilitation period.
Allocation Knee function and VAS pain score
Allocated to intervention (N.=45) Allocated to intervention (N.=46) The HSS knee score, the primary measure, was higher
- Received allocated intervention - Received allocated intervention
(N.=39) (N.=39) in both groups postoperatively than preoperatively (Fig-
- Did not receive allocated intervention - Did not receive allocated intervention ure 2A). After multiple corrected comparisons, the HSS
(N.=6) (N.=7)
- Surgery cancelled (N.=1) - Asked to be discharged (N.=7) scores at two weeks, three months, and 12 months post-
- Asked to be discharged (N.=5)
operatively were higher in the quantitative rehabilitation
training group than in the conventional rehabilitation
Follow-up
training group (P=0.031, P<0.001, P<0.001, respectively)
Lost to follow-up (N.=0) Lost to follow-up (N.=0) (Table II, Figure 2B). Compared with the conventional
- 3 days (N.=0) - 3 days (N.=0)
- 2 weeks (N.=0) - 2 weeks (N.=0) rehabilitation group, the quantitative rehabilitation group
- 3 months (N.=0) - 3 months (N.=0)
- 12 months (N.=0) - 12 months (N.=0)
had significantly higher VAS scores at 24 hours and 3 days
- Discontinuted intervention (N.=0) - Discontinuted intervention (N.=0) postoperatively (P<0.001) (Table II, Figure 3B), but there
was no significant difference in the scores between the
Analysis two groups at two weeks, three months, and 12 months
Analyzed (N.=39) Analyzed (N.=39) postoperatively. The VAS scores gradually decreased after
- 3 days (N.=39) - 3 days (N.=39)
- 2 weeks (N.=39) - 2 weeks (N.=39) surgery in both groups (Figure 3A).
- 3 months (N.=39) - 3 months (N.=39)
- 12 months (N.=39) - 12 months (N.=39) Patient satisfaction and 6-Minute-Walk Test
- Excluded from analysis (give - Excluded from analysis (give
reasons) (N.=0) reasons) (N.=0) The satisfaction rate of the quantitative rehabilitation
Figure 1.—CONSORT inclusion flowchart. training group was significantly higher than that of the

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JIAO QUANTITATIVE REHABILITATION TRAINING AND RECOVERY FROM TKR

100 10
9
QRT (A)
90 8

VAS pain score

7
80 6 RRT (B)
HSS score

5
70 4
3
60 QRT (A) 2
1
RRT (B)
50 0
Preop 24 hours 3 days 2 weeks 3 months 12 months

40 Time points
Preop 2 weeks 3 months 12 months

Time points
Figure 3.—A) Changes in mean VAS pain scores in patients in the quan-
titative rehabilitation training (QRT) and routine rehabilitation training
Figure 2.—A) Changes in HSS scores of patients in the quantitative (RRT) groups before and after surgery; B) pre- and postoperative VAS
rehabilitation training (QRT) and routine rehabilitation training (RRT) pain scores of patients in the quantitative rehabilitation training (QRT)
groups before and after surgery. The error bars indicate the standard de- and routine rehabilitation training (RRT) groups.
viation of the mean. Preop: Preoperative (day of admission); B) HSS
scores of patients in the quantitative rehabilitation training (QRT) and
routine rehabilitation training (RRT) groups preoperatively and postop-
eratively. The top and bottom of the boxes indicate the 25th and 75th
percentiles, and the horizontal line is the median. The whiskers indicate
the minimum and maximum values, and the circles represent outliers.
*P value <0.05.
65

60
Table II.—Changes in HSS and VAS scores by time. Group
Score

QRT RRT Difference QRT

Outcome (N.=39) (N.=39) (95% CI) P value RRT
55
HSS Score*
Pre 50.6±4.1 49.6±4.6 -0.05 (-2.54-2.44) P=0.967† 50
Two weeks 82.1±4.9 78.8±7.9 3.28 (0.30-6.26) P=0.031†
Three months 85.7±3.9 80.7±5.2 5.00 (2.94-7.05) P<0.001†
45
One year 90.1±3.3 86.0±3.6 5.62 (4.20-7.03) P<0.001†
Pre to 2 weeks& 30.5±6.9 27.1±8.7 PCS MCS
P value†† P<0.001 P<0.001 SF-36
Pre to one year& 40.0±6.1 34.4±7.0
P value†† P<0.001 P<0.001 Figure 4.—SF-36 scores of patients in the quantitative rehabilitation
VAS Score* training (QRT) and routine rehabilitation training (RRT) groups at 1 year
Pre 8.6±1.0 8.1±1.0 0.31 (-0.15-0.77) P=0.18† postoperatively. The SF-36 is divided into two parts: physical compo-
Twenty-four hours 6.1±1.4 4.6±1.5 1.46 (0.80-2.12) P<0.001† nent summary (PCS) and mental component summary (MCS).
Three days 4.3±1.3 3.3±1.3 1.00 (0.41-1.59) P<0.001†
Two weeks 2.6±1.0 2.2±0.8 0.39 (0.04-0.80) P=0.07†
Three months 1.5±0.9 1.2±0.8 0.33 (-0.04-0.71) P=0.08† ventional rehabilitation group (Figure 4, Table III) and
One year 1.0±0.7 1.1±0.6 0.77 (-0.30-0.45) P=0.687† walked longer distances in the 6-Minute Walk Test (Fig-
Pre to 24 hours& 1.5±1.8 2.6±1.7 ure 5, Table IV).
P value†† P<0.001 P<0.001
Pre to 12 months& 6.5±1.4 6.2±1.3
Quality of life and time to get out of bed for the first time
P value†† P<0.001 P<0.001
*The values are given as the mean and the standard deviation; ††paired t-test;
†Student’s t-test; &difference between the values obtained preoperatively and
The physical component summary at 12 months postop-
postoperatively. eratively was significantly higher in the quantitative re-
habilitation group than in the conventional rehabilitation
group (P<0.001). In contrast, the mental component sum-
conventional rehabilitation group at discharge, three mary showed no significant difference between the two
months, and 12 months after surgery (P<0.001). The groups (P=0.114). The quantitative rehabilitation group
quantitative rehabilitation group had the highest satisfac- time to get out of bed for the first time after surgery earlier
tion rate (94.87%) at discharge compared with the con- (P<0.001) (Figure 4, Table IV).

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QUANTITATIVE REHABILITATION TRAINING AND RECOVERY FROM TKR JIAO

Table III.—Patient satisfaction at various time points after dis-

charge from hospital.
160 QRT (A)
Satisfaction level QRT RRT P value
(N.=39) (N.=39) 140
RRT (B)
Discharge# P<0.001§§ 120
Very satisfied 27 4

CRP (mg/L)
100
Satisfied 10 20 80
Neither satisfied nor dissatisfied 2 15 60
Dissatisfied 0 1
40
Satisfaction rate 94.87% 61.54%
20
Three months# P<0.001§§
Very satisfied 27 6 0
Preop POD1 POD2 POD3 POD5
Satisfied 9 13
Neither satisfied nor dissatisfied 3 19 Time points
Dissatisfied 0 1
Satisfaction rate 92.31% 43.59%
Twelve months# P<0.001‡ Figure 6.—Mean serum concentrations of C-reactive protein (CRP) in-
Very satisfied 12 3 flammatory markers (A) and interleukin-6 (IL-6) (B) in the perioperative
Satisfied 21 11 period. Preo: Preoperative (morning of surgery).
Neither satisfied nor dissatisfied 6 25 POD: postoperative day.
Dissatisfied 0 0
Satisfaction rate 84.62% 35.90%
§§Fisher’s Exact Test; ‡Pearson χ2; #data are presented as the number (percentage) Inflammatory markers
of patients.
All patients’ postoperative IL-6 and C-reactive protein
(CRP) levels were elevated (Figure 6A, B). IL-6 lev-
els peaked on postoperative day 1 in both groups. At all
postoperative time points, the quantitative rehabilitation
400
group IL-6 levels were significantly higher than those of
the conventional rehabilitation group. Still, there was a
significant difference only on postoperative days 1 and
300
2 (P=0.006, P=0.005, P=0.151, P=0.506). CRP levels
peaked on postoperative day 2. At all postoperative time
Distance

Group
QRT
RRT points, the quantitative rehabilitation group’s CRP levels
200 were significantly higher than those of the conventional
rehabilitation group, but there was a significant difference
only on postoperative day 2 (P=0.164, P<0.001, P=0.093,
100 P=0.356) (Table V).
6-minute walk test
Hospitalization time and complications
Minute

The hospitalization time of the quantitative rehabilitation

Figure 5.—Six-minute-walk test (6MWT) for patients in the quantitative
rehabilitation training (QRT) and routine rehabilitation training (RRT) group was less than that of the conventional rehabilitation
groups during hospitalization. The distance is in meters. group (P<0.001). The incidence of postoperative compli-

Table IV.—Physical component summary at 12 months postoperatively.

Outcome QRT (N.=39) RRT (N.=39) Difference (95% CI) P value
First time of standing after surgery (days) 2 (1, 2) 3 (2, 5) P<0.001§
Hospitalization days (days) 9.7±2.2 12.5±4.5 -4.90 (-6.64- -3.157) P<0.001†
6MWT(meter) 263.1±53.1 263.4±52.3 28.59 (3.23-53.95) P=0.028†
SF-36
PCS 60.3±3.1 50.3±3.6 10.82 (9.28-12.36) P<0.001†
MCS 61.2±2.7 60.3±4.3 1.23 (0.30-2.77) P=0.231†
*The values are given as the mean and the standard deviation; §Mann-Whitney U Test;†Student’s t-test.

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JIAO QUANTITATIVE REHABILITATION TRAINING AND RECOVERY FROM TKR

Table V.—Changes in inflammatory markers at various postop- cols, and their appropriate form remains much debated.
erative time points. Quantitative rehabilitation training has been progressively
Octcome QRT (N.=39) RRT (N.=39) P value optimized by combining the results of previous studies
IL-6 (pg/mL) * and developing progressive phases of training for patients
Pre 4.3±1.8 5.1±1.2 P=0.333†
Postoperative day 1 121.2±40.2 93.6±45.9 P=0.006†
based on the ERAS concept throughout the entire periop-
Postoperative day 2 98.2±39.2 75.9±27.6 P=0.005† erative period.14, 15, 17
Postoperative day 3 47.1±23.2 40.3±22.1 P=0.231† In this study, the quantitative rehabilitation group had
Postoperative day 5 16.5±7.6 15.4±7.3 P=0.401† higher HSS scores at one year compared to the conven-
CRP (mg/L)* tional rehabilitation group, and the scores increased grad-
Pre 5.2±3.1 6.7±3.5 P=0.732†
Postoperative day 1 52.4±21.4 42.3±17.6 P=0.164† ually with time. This indicates that the quantitative reha-
Postoperative day 2 112.8±35.0 73.8±30.0 P<0.001† bilitation program had a positive effect on the recovery of
Postoperative day 3 70.2±23.1 59.1±27.0 P=0.073† the patient’s postoperative knee function. If further loss
Postoperative day 5 19.2±10.1 21.6±12.6 P=0.453† of muscle strength is to be avoided, starting high-intensi-
*The values are given as the mean and the standard deviation.†Student’s t-test. ty training early in the postoperative period should be an
CRP: C-reactive protein; IL-6: interleukin-6.
effective therapy to prevent muscle strength loss, which
is thought to be more effective than restoring muscle
Table VI.—Incidence of postoperative complications. strength.14, 26 Regarding rehabilitation programs and post-
QRT (N.=39) RRT (N.=39) P value operative muscle strength recovery, our results are con-
Complications (N., %) 6 (15.4%) 8 (21.1%) P=0.519‡ sistent with those of Bade et al.,15 who found that early
Wound infection 3 4 high-intensity rehabilitation programs produced greater
DVT 2 3 quadricep strength and joint mobility than low-intensity
Prosthesis loosening 0 0
Stiff knee 1 1
programs in patients after TKR. The difference between
DVT: deep venous thrombosis; ‡Pearson χ2.
their results and ours is that their rehabilitation program
was only based on increasing strength training but did not
make gradual transitions to the rehabilitation program,
cations in the two groups was 15.4% and 21.1%, respec- which can potentially increase the patient’s postoperative
tively, but there was no significant difference (P=0.519) pain. The hospitalization period of TKR patients is an im-
(Table IV, VI). portant period for postoperative functional rehabilitation,
not only to reduce complications but also to develop good
functional exercise habits. Sochart DH27 suggested that
Discussion active exercise was more effective than passive exercise
In this randomized controlled trial, we found that the post- in eliminating blood stagnation and accelerating recovery
of joint function. It is worth noting that active functional
operative HSS scores were higher and increased gradually
exercise is generally carried out gradually on the basis of
with time in the quantitative training group. The degree of
passive activities. In this study, the quantitative rehabilita-
knee function recovery was better compared to the con-
tion training was based on ERAS with progressive tran-
ventional training group. In addition, compared with the
sitional training for the patients. Regarding knee function
conventional rehabilitation group, patients in the quantita- recovery, the quantitative rehabilitation group had better
tive rehabilitation training group had high satisfaction dur- function than the conventional training group, and the
ing follow-up, short hospital stays, and improved quality difference between the groups became more pronounced
of life one year after surgery, but there were no significant with time. In deference to the Sochart DH scholars, pas-
differences in mental health. sive rehabilitation has not been effectively linked to ac-
TKR is traumatic, with varying degrees of preoperative tive rehabilitation exercises in previous studies. In an-
functional deficits, postoperative pain, muscle weakness, other study, Stevens et al. also suggested that progressive
and limited joint movement.22-24 Knee function recovery is postoperative lower extremity strength training could lead
an important outcome after TKR and an important deter- to substantial recovery of quadricep strength and conse-
minant of early functional outcome.25 However, periopera- quent improvement in knee function.28
tive rehabilitation exercises for TKR still have a relative The average number of hospital days of the quantita-
lack of specific, individualized, and standardized proto- tive rehabilitation group in this study was 12 days, which

80 European Journal of Physical and Rehabilitation Medicine February 2024

QUANTITATIVE REHABILITATION TRAINING AND RECOVERY FROM TKR JIAO

was lower than that of the conventional rehabilitation of ERAS and paid attention to the management of the
group; however, the satisfaction rate of the quantitative TKR perioperative period.19, 32 Warm-up activities such
rehabilitation group was higher than that of the conven- as straight leg raising and knee extension exercises were
tional rehabilitation group during the one-year follow- also included to adapt the knee to small flexion activities
up period. This indicates that quantitative rehabilitation before the next stage of rehabilitation, reducing the oc-
training based on the ERAS concept can significantly currence of pain.
reduce the number of hospital days and improve patient Developing a scientifically effective and easily imple-
satisfaction rates after surgery. The reasons for this are mented functional training program is a prerequisite for
twofold. First, the repeated functional training instruc- effective functional training after TKR.33, 34 Studies have
tion before and after surgery reinforces the importance of shown that postoperative functional training should fol-
rehabilitation training in patients’ minds, thus achieving low the principles of early implementation, scientifically
better results. Second, in our contact with patients, we based and systematically applied. The functional training
found that the frequency of communication with patients program was developed based on the training program
and their families had a positive relationship with patient of previous studies, through communication with several
recovery and hospital satisfaction. Communication on rehabilitation physicians, and combined with the ERAS
multiple occasions promoted rapport between the doctor program to develop a quantitative rehabilitation training
and the patient, which led to increased compliance and schedule.
ultimately resulted in shorter hospital stays and increased
Limitations of the study
satisfaction.
Furthermore, the quantitative rehabilitation group had This study does have some limitations. First, the present
a longer distance for the 6-minute walk test and an ear- study was not sufficiently comprehensive to examine the
lier time to get out of bed for the first time after surgery. indicators of functional recovery of the patient’s knee. In
However, in the Stevens-Lapsley et al. study, no differ- the next study, more indicators will be included to assess
ences were found between the two groups in the 6-minute the functional recovery of the patient after surgery fully.
walk test when comparing high-intensity rehabilitation to Second, this study was a single-center study and was not
low-intensity rehabilitation programs.13 The reason for universal, and we will next conduct a multicenter popu-
this analysis may be that the time reported in their study lation-based study to validate our findings. Third, our re-
was 12 weeks postoperatively, whereas we measured this sults apply to patients with severe osteoarthritis who have
during the patient’s hospitalization. The 6-minute walk received their first TKR. It is unclear whether the same
test itself did not require patients to have greater lower results can be obtained in patients with other preoperative
extremity support strength, and the recovery of muscle diagnoses (such as rheumatoid arthritis and traumatic ar-
strength over time was sufficient to balance out the dif- thritis) or in patients who have undergone bilateral knee
ferences between the two groups. replacement.
We found that patient CRP and IL-6 levels began to
decrease on postoperative days 1 and 2 gradually, but Conclusions
there was a statistical difference only on postoperative
day 2. VAS scores were statistically different only at 24 Compared with conventional rehabilitation training,
hours and 3 days postoperatively. This indicates that re- ERAS-based quantitative rehabilitation training is safe
habilitation in both groups did not cause significant ad- and effective. It can accelerate the recovery of knee func-
ditional pain or inflammatory responses in the patients. tion after surgery, shorten hospitalization time, improve
The main reason why patients are reluctant to exercise patient satisfaction, and promote rapid patient recovery.
early is pain. Therefore, attention should be paid to the
multimodal analgesia of early postoperative functional
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Conflicts of interest
The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
Authors’ contributions
Songsong Jiao formulated the idea and the study design; Zhencheng Feng, Jian Huang, and Tianming Dai conducted research, provided research materials,
where responsible for the clinical evaluation of the subjects, and organized data; Songsong Jiao was involved in writing the manuscript; Qingqi Meng carried
out the data analysis and interpretation; Qingqi Meng and Ruijia Liu revised the final draft; all authors confirmed the final manuscript and were responsible

82 European Journal of Physical and Rehabilitation Medicine February 2024

QUANTITATIVE REHABILITATION TRAINING AND RECOVERY FROM TKR JIAO

for the content of the manuscript. Songsong Jiao and Zhencheng Feng contributed equally to this work and should be considered co-first authors. All authors
are responsible for the content and similarity index of the manuscript. All authors read and approved the final version of the manuscript.
Acknowledgments
The authors are grateful for the support of all the doctors, nurses and clinical scientists who worked in the Department of Orthopedics, Guangzhou Red Cross
Hospital, Jinan University, Guangzhou, during the period of patient recruitment. We particularly thank all the subjects for their participation in this study. We
thank LetPub (www.letpub.com) for its linguistic assistance while preparing this manuscript.
History
Article first published online: November 7, 2023. - Manuscript accepted: October 16, 2023. - Manuscript revised: September 22, 2023. - Manuscript received:
January 30, 2023.

Vol. 60 - No. 1 European Journal of Physical and Rehabilitation Medicine 83