Low-Load Unilateral and Bilateral Resistance Training to Restore Lower Limb Function in the Early Rehabilitation After Total Knee Arthroplasty: A Randomized Active-Controlled Clinical Trial

Abstract

Background: Continuous passive motion (CPM) is frequently used during rehabilitation following total knee arthroplasty (TKA). Low-load resistance training (LLRT) using continuous active motion (CAM) devices is a promising alternative. We investigated the effectiveness of CPM compared to LLRT using the affected leg (CAMuni) and both legs (CAMbi) in the early post-operative rehabilitation.

Hypotheses: (I) LLRT (CAMuni and CAMbi) is superior to CPM, (II) additional training of the unaffected leg (CAMbi) is more effective than unilateral training (CAMuni). Materials and Methods: Eighty-five TKA patients were randomly assigned to three groups, respectively: (i) unilateral CPM of the operated leg; (ii) unilateral CAM of the operated leg (CAMuni); (iii) bilateral alternating CAM (CAMbi). Patients were assessed 1 day before TKA (pre-test), 1 day before discharge (post-test), and 3 months post-operatively (follow-up).

Primary outcome: active knee flexion range of motion (ROMFlex).

Secondary outcomes: active knee extension ROM (ROMExt), swelling, pain, C-reactive protein, quality of life (Qol), physical activity, timed-up-and-go performance, stair-climbing performance, quadriceps muscle strength. Analyses of covariances were performed (modified intention-to-treat and per-protocol). Results: Hypothesis I: Primary outcome: CAMbi resulted in a higher ROMFlex of 9.0° (95%CI -18.03-0.04°, d = 0.76) and 6.3° (95%CI -14.31-0.99°, d = 0.61) compared to CPM at post-test and follow-up, respectively.

Secondary outcomes: At post-test, C-reactive protein was lower in both CAM groups compared with CPM. Knee pain was lower in CAMuni compared to CPM. Improved ROMExt, reduced swelling, better stair-climbing and timed-up-and-go performance were observed for CAMbi compared to CPM. At follow-up, both CAM groups reported higher Qol and CAMbi showed a better timed-up-and-go performance. Hypothesis II: Primary outcome: CAMbi resulted in a higher knee ROMFlex of 6.5° (95%CI -2.16-15.21°, d = 0.56) compared to CAMuni at post-test.

Secondary outcomes: At post-test, improved ROMExt, reduced swelling, and better timed-up-and-go performance were observed in CAMbi compared to CAMuni. Conclusions: Additional LLRT of the unaffected leg (CAMbi) seems to be more effective for recovery of function than training of the affected leg only (CAMuni), which may be mediated by positive transfer effects from the unaffected to the affected limb (cross education) and/or preserved neuromuscular function of the trained, unaffected leg. Trial Registration: ClinicalTrials.gov Identifier: NCT02062138.

Keywords: continuous passive motion; controlled active motion; cross education; interlimb transfer; range of motion; strength training.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Jacksteit, Stöckel, Behrens, Feldhege, Bergschmidt, Bader, Mittelmeier, Skripitz and Mau-Moeller.

Figures

Figure 1

Overview of groups, interventions, measuring points, and relevant primary and secondary outcomes.

Figure 2

Consort participant flow diagram showing enrollment, intervention allocation, number of participants at different time points, and number of patients included in modified intention-to-treat analysis.

Figure 3

Results of the modified intention-to-treat analyses for (A) the primary outcome active knee flexion range of motion (ROM), (B) timed-up-up-and-go-performance and (C) quality of life (SF-36 score) at post- and follow-up tests, respectively. CPM, continuous passive motion; CAMuni, continuous active motion unilateral; CAMbi, continuous active motion bilateral; + Denotes the clinical relevance (Cohen's d effect size) for post-hoc comparisons between groups: ++ medium effect (Cohen's d 0.50–0.79), +++ large effect (Cohen's d ≥ 0.80).