X10 Therapy References and Resources


A New Non-Surgical Alternative to Manipulations Under Anesthesia Following Knee Replacement 

Stiff knee occurs in between 2% and 23% of total knee arthroplasty patients. Resolution of a stiff knee is critical for patients’ quality of life following a TKA. Historically, treatment options include physical therapy, manipulation under anesthesia, arthroscopic lysis, and open lysis. Excluding physical therapy, the other options all require anesthesia, with procedures usually being done in a hospital or surgical center. 

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CMS Takes Action to Modernize Medicare Home Health

On July 2, CMS proposed significant changes to the Home Health Prospective Payment System (PPS) to strengthen and modernize Medicare, drive value, and focus on individual patient needs rather than volume of care. Specifically, CMS is proposing changes to improve access to solutions via remote patient monitoring technology, and to update the payment model for home health care.

“Today’s proposals would give doctors more time to spend with their patients, allow home health agencies to leverage innovation and drive better results for patients,” said CMS Administrator Seema Verma. “The redesign of the home health payment system encourages value over volume and removes incentives to provide unnecessary care.”

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How often is functional range of motion obtained by manipulation for stiff total knee arthroplasty?

Purpose To evaluate how often manipulation under anesthesia (MUA) can achieve functional flexion ≥ 90 degrees and identify predictor for successful outcome of MUA for stiff total knee arthroplasty (TKA).

Methods Demographic data, range of motion, and surgical and anesthetic information of 143MUAs were retrospectively analyzed from 2000 to 2011. Results One-hundred thirty-six out of 143 patients (95 %) improved mean range of motion (ROM) from pre-MUA 62±17° to final ROM 101±21° (p<0.001). Flexion ≥ 90 degrees was achieved in 74% (106/143) of patients. Regional anesthesia was identified as predictor of successful MUA outcome (p=0.007, OR: 8.5, 95 % CI: 1.2-66.7).

Conclusions Although the proportion of patients regaining flexion ≥ 90 degrees following MUA was less than those patients with simple overall ROM increase, the functional flexion ≥ 90 degrees was achieved in the

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Are Computer-Controlled, Pressure Modulated Knee Rehabilitation Machines Valuable Following Knee Arthroplasty?

Background: To determine if a patented new computer controlled, pressure modulated knee rehabilitation machine was more effective, in rehabilitation of total knee arthroplasty, than the continuous passive motion machine utilizing Cochrane Review data. 

Methods: Prospective study of 197 patients: 59 outpatient rehabilitation facilities; 155 homebased care, and 7 skilled nursing facilities. Patients were prospectively treated with pressure modulated knee rehabilitation and standard rehabilitation for total knee arthroplasty. Range of motion (RoM) was compared (via ANOVA) with the Cochrane continuous passive motion study. We also evaluated RoM outcomes versus start day of pressure modulated knee rehabilitation use. 

Findings: Pressure modulated knee rehabilitation patient’s ROM, at 30 days, exceeded 116°; significantly greater than all short-term (6 weeks) Cochrane Review studies (83°). Patients using the pressure modulated knee rehabilitation six or more days after surgery had a significantly lower 14-day RoM than patients who began on days 1-5 following surgery. 

Interpretation: The pressure modulated knee rehabilitation patients increase their RoM following total knee arthroplasty significantly more than continuous passive motion users. 

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X10 Study, The Value of X10 Therapy Resarch


Quadriceps Strength and the Time Course of Functional Recovery After Total Knee Arthroplasty

Study Design: Prospective study with repeated measures.Objectives: The overall goal of this investigation was to describe the time course of recovery of impairments and function after total knee arthroplasty (TKA), as well as to provide direction for rehabilitation efforts. We hypothesized that quadriceps strength would be more strongly correlated with functional performance than knee flexion range of motion (ROM) or pain at all time periods studied before and after TKA.

Background: TKA is a very common surgery, but very little is known regarding the influence of impairments on functional limitations in this population. Methods and Measures: Forty subjects who underwent unilateral TKA followed by rehabilitation, including 6 weeks of outpatient physical therapy, were studied. Testing occurred at 5 time periods: preoperatively, and at 1, 2, 3, and 6 months after surgery. Test measures included quadriceps strength, knee ROM, timed up-and-go test, timed stair-climbing test, bodily pain, and general health and knee function questionnaires.

Results: Subjects experienced significant worsening of knee ROM, quadriceps strength, and performance on functional tests 1 month after surgery. Quadriceps strength went through the greatest decline of all the physical measures assessed and never matched the strength of the uninvolved limb. All measures underwent significant improvements following the 1-month test. Quadriceps strength was the most highly correlated measure associated with functional performance at all testing sessions.

Conclusions: Functional measures underwent an expected decline early after TKA, but recovery was more rapid than anticipated and long-term outcomes were better than previously reported in the literature. The high correlation between quadriceps strength and functional performance suggests that improved postoperative quadriceps strengthening could be important.

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Quadriceps StudyQuadriceps Study, Knee Replacement


Comparison of Clinic- and Home-Based Rehabilitation Programs After Total Knee Arthroplasty

After primary total knee arthroplasty, patients who completed home-based rehabilitation performed similarly to patients who completed clinic-based rehabilitation during the first 52 weeks after surgery.

That all nine criterion measures in the current study produced similar results for the per protocol and the intent-to-treat analyses suggests that these findings apply across a spectrum of disease-specific, joint-specific, and functional variables. Overall, the additional patient monitoring, adjustment of program, and motivational support available through clinic-based rehabilitation was not advantageous for the population studied.

These findings were not confounded by any interactions with surgeon, type of prosthesis, or time since surgery. The current results extend those of previous studies of meniscectomy5,7,10 and anterior cruciate ligament reconstruction1,3,4,11 populations, and corroborate a previous retrospective study using a total knee arthroplasty sample.8

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Knee Surgery Comparison


Aspects of physiotherapy in the peri-operative management of total knee arthroplasty patients

Knee osteoarthritis (OA) is a prevalent musculoskeletal condition affecting older people, causing pain, physical disability and reduced quality of life1. Relevant therapeutic approaches include drug therapy, weight loss, patient education programmes, surgery, walking/household aids or adaptations, and therapeutic exercise2.

Total knee arthroplasty (TKA) is considered the treatment of choice for patients with intractable pain and substantial functional disabilities who have not had acceptable relief and functional improvement after conservative treatment 3-5. Modern TKA began about 1970. Nowadays, TKA represents a very successful surgical intervention, with reports documenting 15-year survivorship of over 90%6. Worldwide, 500,000 to 800,000 total knee replacements are performed annually 7 8.

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Risk Factors, Outcomes, and Timing of Manipulation Under Anesthesia After Total Knee Arthroplasty

Background: Knee stiffness requiring manipulation under anesthesia (MUA) is an undesirable outcome following total knee arthroplasty (TKA), but risk factors for, and optimal timing of, MUA remain unclear.

Methods: Primary TKAs performed at a single center were retrospectively reviewed. Clinical variables were compared between patients who underwent MUA and those who did not; variables that differed were utilized to identify an appropriately matched control group of non-MUA patients. The MUA group was divided into early (MUA 6 weeks from index) and late (>6 weeks) subgroups. Flexion values at multiple time points were compared.

Results: In total, 1729 TKA patients were reviewed; MUA was performed in 62 patients. Patients undergoing MUA were younger (55.2 vs 65.3 years, P < .001) and had higher rates of current smoking (21.0% vs 7.3%, P < .001) and prior procedure (59.7% vs 40.4%, P . .002), most commonly arthroscopy; a control group of patients not requiring MUA, matched on the basis of these variables, was identified. While no difference in pre-TKA flexion existed across groups, final flexion in the early MUA group (106.7) was equivalent to that of controls (115.6), while final flexion in the late MUA group was not (101.3, P ..001).

Conclusion: TKA patients undergoing MUAs were younger, more likely to be current smokers, and more likely to have undergone prior knee surgery. Even in patients with severe initial postoperative limitations in range of motion, MUA within 6 weeks may allow for final outcomes that are equivalent to those experienced by similar patients not requiring manipulation

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Risk Factors, Knee Replacement


High‑intensity preoperative training improves physical and functional recovery in the early post‑operative periods after total knee arthroplasty: a randomized controlled trial B

Purpose The benefits of preoperative training programmes compared with alternative treatment are unclear. The purpose of this study was to evaluate the effectiveness of a high-intensity preoperative resistance training programme in patients waiting for total knee arthroplasty (TKA).

Methods Forty-four subjects (7 men, 37 women) scheduled for unilateral TKA for osteoarthritis (OA) during 2014 participated in this randomized controlled trial. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Physical Functioning Scale of the Short Form-36 questionnaire (SF-36), a 10-cm visual analogue scale (VAS), isometric knee flexion, isometric knee extension, isometric hip abduction, active knee range of motion and functional tasks (Timed Up and Go test and Stair ascent–descent test) were assessed at 8 weeks before surgery (T1), after 8 weeks of training (T2), 1 month after TKA (T3) and finally 3 months after TKA (T4).

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High Intensity



Continuous passive motion following total knee arthroplasty in people with arthritis


Arthritis of the knee is a common problem causing pain and disability. If severe, knee arthritis can be surgically managed with a total knee arthroplasty. Rehabilitation following knee arthroplasty often includes continuous passive motion (CPM). CPM is applied by a machine that passively and repeatedly moves the knee through a specified range of motion (ROM). It is believed that CPM increases recovery of knee ROM and has other therapeutic benefits. However, it is not clear whether CPM is effective.


To assess the benefits and harms of CPM and standard postoperative care versus similar postoperative care, with or without additional knee exercises, in people with knee arthroplasty. This review is an update of a 2003 and 2010 version of the same review.

Search methods

We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12), MEDLINE (January 1966 to 24 January 2013), EMBASE (January 1980 to 24 January 2013), CINAHL (January 1982 to 24 January 2013), AMED (January 1985 to 24 January 2013) and PEDro (to 24 January 2013).

Selection criteria

Randomised controlled trials in which the experimental group received CPM, and both the experimental and control groups received similar postoperative care and therapy following total knee arthroplasty in people with arthritis.

Data collection and analysis

Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias. The primary outcomes of interest were active knee flexion ROM, pain, quality of life, function, participants’ global assessment of treatment effectiveness, incidence of manipulation under anaesthesia and adverse events. The secondary outcomes were passive knee flexion ROM, active knee extension ROM, passive knee extension ROM, length of hospital stay, swelling and quadriceps strength.We estimated effects for continuous data as mean differences or standardised mean differences (SMD), and effects for dichotomous data

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Cochrane CPM Study


Recovery Timeline for TKR: Rehabilitation Stages and Physical Therapy

When you have total knee replacement (TKR) surgery, the recovery and rehabilitation process plays a crucial role in helping you get back on your feet and resume an active lifestyle. It can help you heal from surgery faster and greatly improve your chances for long-term success.

It’s important that you commit to a plan and push yourself to do as much as possible each day. Read on to learn what you can expect during the critical 12 weeks of recovery and rehab, and how to set goals for your healing.

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Knee Recovery Tmeline