Background: Despite Total Knee Replacement (TKR) patients routinely receiving physical therapy in the immediate and early post-operative phase, there is a paucity of research into the optimal exercise protocols in both the acute inpatient setting and early period after discharge. The acute period after TKR has become increasingly important for post-operative rehabilitation as average length of stay (LOS) rates decline worldwide. Pedaling has often been recommended by clinicians after TKR for rehabilitation, but to our knowledge, there has been no investigation into its utility in the acute post-operative setting. Therefore, we performed a randomized controlled trial evaluating the efficacy of pedaling in the acute postoperative period. Methods: Sixty TKR patients were randomized into either a three exercise pedaling (Pedaling-based) or ten exercise non-pedaling (Multi-exercise) physical therapy postoperative protocol. Outcomes were assessed at 2 days, 2 weeks and 4 months, and included physical tests of function, patient reported outcomes, and other perioperative measures. Results: The primary outcome, the Six Minute Walk Test (6MWT), was significantly greater in the Pedaling-based group than the Multi-exercise group at 2 days post-operatively (mean difference 66 meters, p = .001). Other functional tests, the 10-meter walk speed (10MWT) and the Timed Up and Go (TUG) test, were both significantly superior in the three exercise pedaling group at 2 days (10MWT p = .016; TUG p = .020) as was the patient reported Oxford Knee Score (OKS) (p = .034). The OKS, continued to be superior at 2 weeks (p = .007), and the VAS score was significantly better for the Pedaling-based group at all timepoints assessed. Length of stay was also significantly shorter by a half day, for the

BackgroundTotal knee replacement (TKR) patients participate in early supervised exercise therapy programs, despite a lack of evidence for such programs or the optimal type, duration or frequency to provide the best clinical outcomes. As hospital stay rates decrease worldwide, the first days after joint replacement surgery are of increasing clinical importance. The purpose of this study was to investigate any reported effects of published early exercise therapy following TKR surgery.MethodsDatabases PubMed, CINAHL, Embase, Cochrane, and Pedro were searched up to August 2018 for trials which investigated an early supervised exercise therapy, commencing within 48 h of surgery. Risk of bias was evaluated using a Modified Downs and Black Checklist and meta-analysis of results was conducted using Review Manager (RevMan). Standardised Mean Differences (SMD) or Mean Differences (MD) and 95% confidence intervals were calculated and combined in meta-analyses.ResultsFour studies (323 patients) that used four different interventions were identified, including Modified Quadriceps Setting, Flexion Splinting, Passive Flexion Ranging and a Drop and Dangle Flexion regime. Patients receiving the Drop and Dangle flexion protocol had superior flexion in the first 2 days after TKR and at discharge, the Flexion Splint patients were discharged earlier and had greater flexion at 6-weeks postoperatively, and the Modified Quadriceps Setting group showed greater hamstring and gluteal muscle strength. Results of the methodological quality assessment showed included studies were of moderate quality. The meta-analysis included 3 of the 4 trials and found no significant differences between groups in maximum knee flexion (MD = 1.34; 95% CI, − 5.55–8.24) or knee society scores (MD = − 1.17; 95% CI, − 4.32–1.98) assessed at 6 weeks post-operatively.ConclusionThe paucity and heterogeneity of existing studies that examine early supervised exercise therapy following TKR surgery makes it challenging for clinicians to deliver high-quality evidence-based exercise programs in the early postoperative period. Although superior knee flexion range was found across differing regimes, the meta-analysis showed no significant difference in this outcome between groups at 6 weeks. The results of this review show high quality randomized clinical trials are urgently needed to evaluate the impact of early exercise following TKR surgery.Trial RegistrationThis review was registered with PROSPERO (CRD42017081016).Electronic supplementary materialThe online version of this article (10.1186/s12891-019-2415-5) contains supplementary material, which is available to authorized users.