Adv Exp Med Biol - Clinical and Experimental Biomedicine (2018) 1: 1–9

https://doi.org/10.1007/5584_2018_187
# Springer International Publishing AG, part of Springer Nature 2018
Published online: 29 March 2018

Improvement in Gait Pattern After Knee

Arthroplasty Followed by Proprioceptive
Neuromuscular Facilitation Physiotherapy

Joanna Jaczewska-Bogacka and Artur Stolarczyk

Abstract postsurgical pain was evidently less. We con-

The aim of the study was to assess the influ- clude that the individually tailored PNF reha-
ence of a physiotherapy program based on bilitation program is superior compared to a
proprioceptive neuromuscular facilitation standard recommendation of home-based
(PNF) on kinematic gait pattern after total physiotherapy in terms of improving gait kine-
knee arthroplasty. This comparative study matic pattern as well as psychological aspects
included two groups of patients qualified for related to pain perception in patients after knee
total surgical knee joint replacement due to arthroplasty.
osteoarthritis: a study group and a control
group, either consisting of 28 patients of a Keywords
matched age range of 55–90 years. Following Gait kinematics · Gait pattern · Joint
surgery, 4 days after standard postoperative replacement · Knee arthroplasty ·
rehabilitation, the study patients were Physiotherapy · Proprioceptive neuromuscular
subjected to a 3-week-long therapist-assisted facilitation · Rehabilitation
rehabilitation based on PNF principles
(10 sessions of 75 min each), whereas control
patients were discharged with instructions on 1 Introduction
how to exercise in the home setting. The out-
come consisted of spatial-temporal gait It is estimated that there were approximately
parameters that were assessed at three time 1.4 M knee arthroplasty surgeries carried out
points: a day before surgery and then around the world in 2015 (Szöts et al. 2015).
1 month and 6 months after. The findings Studies show that about 20% postoperative
were that PNF caused substantial, sustained arthroplasty patients still complain about chronic
improvements in gait kinematics, shortening knee joint pain (Beswick et al. 2012) and 15% of
the stance phases, gait cycle duration, and patients suffer from pain, despite the absence of
double support phase and prolonging swing any underlying reasons in radiological joint
phase velocity, gait velocity, cadence, step images (Lee et al. 2015). Pathological gait pattern
length, and gait cycle length. Also, after surgery also is observed in patients who do

J. Jaczewska-Bogacka (*)
Lekmed Medical Center, Warsaw Medical University, A. Stolarczyk
Warszawa, Poland Department of Clinical Rehabilitation, Warsaw Medical
e-mail: [email protected] University, Warsaw, Poland

1
2 J. Jaczewska-Bogacka and A. Stolarczyk

not experience pain, which may result from the the control patients above outlined plus individual
inability to adjust to new conditions (Stan and post-surgery exercise program, based on proprio-
Orban 2014). It is necessary to improve therapeu- ceptive neuromuscular facilitation. All the
tic procedures after knee arthroplasty to maximize patients were examined three times: 1 day before
the effectiveness of surgery and improve the surgery, 1 month after surgery, and 6 months after
patients’ quality of life. surgery.
The aim of the present study was to assess the Knee arthroplasty consisted of the implanta-
influence of a physiotherapy program based on tion of a posterior-stabilized Zimmer Nexgen
proprioceptive neuromuscular facilitation, used in knee endoprosthesis. Surgical procedures were
total knee arthroplasty, on the patients’ gait pat- always performed by the same surgeon under
tern in 1 month and 6 months after surgery com- the general same conditions.
pared with standard instructions on how to
exercise at home.
2.2 Rehabilitation Program

2 Methods In the first week after surgery, patients from both

study and control groups underwent an early post-
2.1 Study Organization operative rehabilitation. Physiotherapy started
24 h after surgery and included four 40-min
The study was approved by the Bioethics Com- sessions in the patient’s room. The sessions
mittee of Warsaw Medical University in Poland consisted of breathing exercises, exercises
(approval no. KB/123/2012). The study included improving blood circulation, isometric exercises,
patients qualified for total surgical knee knee joint mobilization, exercises in the standing
arthroplasty due to osteoarthritis, treated in the posture, proper walking on crutches, and cooling
Orthopedics and Rehabilitation Clinic of the Sec- the joint with cold compresses. After 4 days of
ond Medical Department of Warsaw Medical postoperative rehabilitation, the patient was
University in Warsaw, Poland, in 2013–2014. discharged and recommended to continue the
Patients were divided into a control same kind of exercise with increasing intensity
(23 women and 5 men, age 68.1
6.9, range and number of repetitions.
55–80 years, mean body mass index (BMI) After further 4 days of exercises in the home
31.5
3.8 kg/m2) and study groups (19 women setting, the study patients participated in 3-week-
and 9 men, age 68.7
8.8, range 55–90 years, long proprioceptive neuromuscular facilitation
BMI 31.7
5.6 kg/m2). Patients of either group physiotherapy. The program included ten
had a lower limb operated on and had a different meetings with a physiotherapist (three times a
rehabilitation program. All the patients had had week) of 75-min duration each. Figure 1
knee joint pain before surgery for more than illustrates some of the interventions used. A phys-
3 years, and they had no exercise program before iotherapy session started with reducing pain and
surgery. Patients of the control group were swelling, relaxing tense muscles, and increasing
recruited in 2013. These patients performed two mobility (techniques, hold-relax, contract-relax,
types of recommended post-surgery exercise at and rhythmic initiation). Then, the core muscles
home (active knee flexion and extension and iso- were activated to improve trunk and lower limb
metric quadriceps contraction). During the fol- stability (techniques, stabilizing reversals and
lowing year, recruitment for patients of the rhythmic stabilization). Also, techniques increas-
study group took place. These patients had ing muscle strength and endurance and improving
home-based exercise akin to that performed by coordination (combination of isotonic
Improvement in Gait Pattern After Knee Arthroplasty Followed by. . . 3

Fig. 1 Examples of proprioceptive neuromuscular facilitation (PNF) treatment

contractions and dynamic reversals) and proprio- objective, quantitative analysis of temporospatial
ception and balance training were used in the parameters. Three sequential trials were
session. The ultimate goal was to restore the performed to calculate the mean results. The
proper gait pattern, so that at the end of a session, trial results were compared against average
different gait phases were directly facilitated. results provided by the BTS system database
Additional interventions included patella mobili- (Table 1).
zation, scar mobilization, and hands-off balance
exercises.
2.4 Statistical Analysis

2.3 Rehabilitation Outcomes Differences between the study and control

patients were statistically assessed with Student’s
BTS Smart system (BTS Bioengineering Corp., t-test and the Mann-Whitney U test. Results
Brooklyn, NY), a high-precision optoelectronic within a group were compared using the
system, equipped with infrared illuminators, for one-way ANOVA with repeated measures or its
the biomechanical motion analysis, was used to nonparametric alternative, the Friedman test.
assess the patients’ gait pattern as they walked a Additionally, lower and upper limits of 95% con-
distance of 10 m. The system enables the fidence intervals for variances were calculated.
 4

Table 1 Gait pattern changes after knee arthroplasty

Control patientsa Study patientsb
Surgery Surgery Healthy adults
Gait pattern Before After 1 month After 6 months Before After 1 month After 6 months 65 + years oldc
Stance phase – operated limb (s) 1.08
0.36 1.08
0.62 1.03
0.45 1.03
0.34 0.80
0.14 { 0.72
0.11 {*^ 0.63
0.02 right
Stance phase – non-operated limb (s) 1.11
0.38 1.10
0.77 1.03
0.50 1.06
0.35 0.82
0.14 {* 0.72
0.09 {*^ 0.63
0.04 left
Stance phase (%) 67.80
6.60 67.90
5.30 67.90
5.30 67.70
7.10 62.70
3.80 {* 61.90
3.80 {* 59.60
1.20
Swing phase – operated limb (s) 0.49
0.07 0.47
0.09 0.46
0.09 0.46
0.07 0.47
0.06 0.44
0.05 0.43
0.02 right
Swing phase non-operated limb (s) 0.45
0.07 0.46
0.07 0.47
0.07 0.43
0.06 0.47
0.05 0.45
0.05 0.43
0.02 left
Gait cycle duration (s) 1.56
0.38 1.56
0.81 1.50
0.53 1.49
0.34 1.27
0.17 {* 1.16
0.14 {*^ 1.06
0.03
Double-limb support (s) 19.10
6.90 17.50
5.00 18.20
6.30 19.90
9.30 13.30
3.40 {* 11.40
3.90 {*^ –
Swing phase velocity (m/s) 1.38
0.41 1.59
0.45 1.66
0.42 * 1.44
0.41 1.76
0.37 * 2.04
0.51 {*^ 3.30
0.14
Gait velocity (m/s) 0.46
0.22 0.54
0.22 0.59
0.18 * 0.51
0.22 0.69
0.17{* 0.83
0.25 {*^ 1.39
0.06
Cadence (steps/min) 80.9
16.5 86.0
18.7 87.0
16.1 83.9
17.2 95.80
11.8 {* 105.0
12.1 {*^ 113.8
4.3
Step length – operated limb (m) 0.33
0.12 0.36
0.12 0.39
0.10 0.33
0.11 0.39
0.11 * 0.42
0.10 * 0.73
0.02
Gait cycle length (m) 0.73
0.22 0.79
0.20 0.84
0.19 * 0.74
0.23 0.89
0.16 * 0.96
0.21 {*^ 1.47
0.08
Step width (m) 0.19
0.04 0.18
0.03 0.18
0.04 0.18
0.04 0.17
0.04 0.18
0.04 0.13
0.01
Pain (VAS score) 6.70
2.60 4.90
2.40 3.50
2.50 * 7.70
2.30 2.90
1.60 {* 1.50
1.40 {* –
Data are means
SD. p <0.05 denotes statistically significant differences, { study patients vs. corresponding feature in control patients, * after vs. before surgery in a group of
patients, ^ 6 months vs. 1 month after surgery in a group
a
Standard rehabilitation, bproprioceptive neuromuscular facilitation (PNF) physiotherapy, cresults representing normal values from healthy adults (database of BTS Bioengineer-
ing Corp., Brooklyn, NY), VAS, visual analog scale
J. Jaczewska-Bogacka and A. Stolarczyk
Improvement in Gait Pattern After Knee Arthroplasty Followed by. . . 5

A p-value < 0.05 defined statistically significant There were no major changes in swing phase
differences. The effect size was calculated based duration before and after surgery in either control
on Pearson’s (r) and Cohen’s (d) coefficients. or study patients.

3 Results 3.2 Gait Cycle Duration and Double-

Limb Support Phase
3.1 Stance and Swing Phase
Duration Gait cycle duration was longer before surgery in
both control and study patients than the reference
The stance phases in both study and control in healthy subjects. It shortened significantly in
patients, concerning both operated and the study, but not control, patients after surgery;
non-operated limbs, were comparable before sur- the shortening progressed with time after surgery
gery and were much, on average, 50 s longer than amounting to about 22% 1 month and 32%
the reference in the age-matched healthy subjects. 6 months after surgery ( p < 0.05). There also
Both 1 and 6 months after surgery in the study was a large effect size (r ¼ 34, r ¼ 0.55).
patients, stance phase of the operated limb was Likewise, double-limb support phase, which
significantly shorter (0.80
0.14 s and was in a range of 19–20 s before surgery in both
0.72
0.11 s, respectively) than those in the groups of patients, shortened significantly and
control patients after surgery (1.08
0.62 s and progressively 1 and 6 months after surgery by
1.03
0.50 s, respectively). There was a large about 33% and 43% in the study, but not control,
effect size in the study patients (r ¼ 0.44 and patients ( p < 0.05), with a large effect size
r ¼ 0.62) after both 1 and 6 months post-surgery. (d ¼ 0.9 and r ¼ 0.6) (Table 1).
The stance phase also was shorter in these
patients 6 months after surgery compared with
its duration 1 month after surgery, the effect not 3.3 Swing Phase Velocity, Mean Gait
observed in the control patients. Further, similar Velocity, and Cadence
changes in stance phase were also present in the
non-operated limb (Table 1). Before surgery, swing phase velocity was smaller
Before surgery, the relation of stance phase to in both control and study patients than the refer-
swing phase in the patients examined was ence in healthy subjects. Although it increased
distorted, with the stance constituting about 68% 6 months after surgery in the control patients,
of the gait cycle. The contribution of the stance to the increase was distinctly greater, by 22% and
the gait cycle decreased significantly to 63% after 42% 1 and 6 months, respectively, and signifi-
1 month and 62% 6 months after surgery in the cantly progressive ( p < 0.05) with a large effect
study patients, whereas this contribution failed to size (d ¼ 0.8) 6 months after surgery in the study
change appreciably in the control patients. The patients (Table 1).
relation between the stance and swing phases in Mean gait velocity amounted to about 0.50 m/
the study patients was within the norm for a s in both control and study patients before sur-
healthy 65+ years of age adult 6 months after gery, which was about threefold smaller than the
surgery. There was a large effect size in these reference in healthy subjects. Akin to swing
patients (d ¼ 1.04 and r ¼ 0.6) after both 1 and velocity, gait velocity increased 6 months after
6 months post-surgery. In the control patients, by surgery in control patients, and the increase was
contrast, relation between stance and swing distinctly greater, by 35% and 63% 1 and
phases was distorted to the same extent before 6 months, respectively, and significantly progres-
and 1 and 6 months after surgery (Table 1). sive ( p < 0.05) with a large effect size (d ¼ 0.75,
6 J. Jaczewska-Bogacka and A. Stolarczyk

d ¼ 1.08) 6 months after surgery in the study protocols is largely unknown. This study
patients, nearing the gait velocity of the reference demonstrates that the individual-targeted physio-
healthy subjects. therapy program introduced in the first month
Likewise, cadence, expressed in steps per min- after surgery significantly improves gait pattern
ute, was, on average, comparable – 81 steps/min of a patient who underwent a knee joint replace-
in control and 84 steps/min in study patients – but ment. The technique of proprioceptive neuromus-
smaller compared with the reference of about cular facilitation we employed in the study is in
114 steps/min in healthy subjects. While the num- accord with the rehabilitation guidelines for knee
ber of steps failed to change appreciably in the arthroplasty of the Osteoarthritis Research Soci-
control subjects, it significantly and progressively ety International (OARSI) and Ottawa Panel
increased by 14% and 25% 1 and 6 months after evidence-based clinical practice (Peter et al.
surgery in the study patients ( p < 0.05), with a 2011; Zhang et al. 2010; Brosseau et al. 2005).
large effect size (r ¼ 0.3, d ¼ 1.3) (Table 1). Artz et al. (2013) have investigated the effects
of various routines of physiotherapy in patients
discharged after total knee and hip arthroplasty
3.4 Step Length, Gait Cycle Length, from 24 high-volume NHS orthopedic clinics in
and Step Width England and Wales. There were eleven clinics in
which the majority of patients participated in
Step and gait cycle lengths in patients qualified group exercises and five in which individual
for surgery were in a range of 0.33 m and 0.73 m, physiotherapy was employed. The authors con-
respectively, both about twofold shorter than the clude that although none of the clinics refer post-
respective reference in healthy subjects. Both operative patients for rehabilitation as a standard
variables tended to increase in control patients procedure, physiotherapy after knee arthroplasty
6 months after surgery; the increases were dis- is a more common practice than after hip
tinctly and progressively greater than 1 and arthroplasty and is more commonly executed in
6 months after surgery in the study patients group exercises. Oatis et al. (2014) have carried
( p < 0.05), although they remained short of the out a 6-month-long postoperative observation of
reference levels in healthy subjects (Table 1). knee arthroplasty patients in different hospitals
Step width in both control and study patients across the USA. It turns out that there is a signifi-
suffering from knee osteoarthritis was greater cant difference concerning the type of interven-
than the reference in healthy subjects, on average, tion used, number of repetitions, resistance,
20 cm vs. 13 cm, respectively. There were no frequency of exercises, and the time of rehabilita-
appreciable changes in step width in either tion commencement. A meta-analysis concerning
group of patients after surgery. the effectiveness of physiotherapy in postopera-
Individual-targeted neuromuscular facilitation tive knee arthroplasty has demonstrated the lack
treatment leads to a significant decrease in pain of improvement in gait pattern in patients
perception score, which was already evident performing general exercises. However, gait
1 month after knee arthroplasty surgery. A velocity is improved in patients practicing weight
decrease in pain symptoms was sustained over bearing on the operated limb and various ways of
time as pain further tapered off 6 months after walking (Artz et al. 2015). Hausdorf and Kang
surgery (Table 1). have demonstrated that gait cycle duration in the
elderly associates with the strength of quadriceps,
the range of movability, and the gait velocity
4 Discussion (Hausdorff et al. 2011; Kang and Dingwell
2008). Patients experiencing knee joint pain tend
The influence on gait pattern of knee joint to walk much slower than healthy persons do,
replacement has already been investigated. How- which enhances the risk of losing stability while
ever, the effectiveness of different rehabilitation walking. Those and other studies demonstrate
Improvement in Gait Pattern After Knee Arthroplasty Followed by. . . 7

that gait velocity, step length, and range of limb phase and gait velocity (Taş et al. 2014).
motion are persistently reduced post-surgery, and According to Hamacher et al. (2011), patients
the slow developing improvements fall short of who fall also feature extended stance phase,
motion level seen in healthy subjects (Casartelli decreased gait velocity, and shortened step
et al. 2013; Alnahdi et al. 2011; Bennett et al. length. Therefore, rehabilitation program after
2008). knee arthroplasty should combine interventions
In the present study, we demonstrate that an aimed at improving stability, proprioception, neu-
individually tailored physiotherapy program, romuscular control, and facilitation of different
based on proprioceptive neuromuscular facilita- gait phases. A change of spatiotemporal gait pat-
tion, significantly improved gait velocity by tern may influence walking stability and amelio-
shortening the stance and double support phases. rate balance disorders.
Gait velocity improved already 1 month after Stan and Orban (2014) have demonstrated a
surgery, and the improvement was sustained and significant difference in the average duration of
even advanced 6 months after surgery in patients loading between operated and non-operated knee
subjected to individually tailored physiotherapy, joints, being 1.03 s and 1.08 s, respectively. In
but not in patients subjected to standard physio- healthy persons, the duration of 0.8 s was dis-
therapy. Gait velocity of healthy adults between tinctly lower, compared to that in patients both
30 and 60 years of age varies between 1.2 and before and after surgery. The extension of stance
1.5 m/s (Blanke and Hageman 1989). It decreases duration of non-operated limb together with
to 1.0–1.2 m/s in healthy elderly (Brach et al. decreased gait velocity seems a postoperative
2007). Newman et al. (2003) have demonstrated strategy for load avoidance. Such asymmetry
that gait velocity required for safe street crossing may, however, lead to overloading of the other
is 1.2 m/s. In a study by Alice et al. (2015), gait operated limb. In the present study, duration of
velocity failed to improve in a half of the loading of the operated limb shortened from
90 patients 3 months after knee joint arthroplasty, 1.03
0.34 s to 0.72
0.11 s 6 months after
and it was even worse after than before surgery in surgery, and the discrepancy between operated
every fifth patient. Those patients, however, were and non-operated limb was leveled off in patients
not subject to an individual physiotherapy. Like- subjected to individual neuromuscular facilita-
wise, Hiyama et al. (2015) have demonstrated tion, but not standard, physiotherapy. The
that surgery alone may not be enough for a clear findings underscore the potential benefit to be
benefit in gait pattern. Taş et al. (2014) have gained from individually tailored therapy.
demonstrated the following changes in gait kine- McClelland et al. (2011) have actually
matics in severe knee osteoarthritis patients in observed a worsening of gait velocity, cadence,
stage 3: reductions in gait velocity, cadence, and step length in patients who were 12 months
step length, and gait cycle length and increases after knee replacement surgery, compared with
in the duration of gait cycle, step, one-legged healthy persons. That observation contrasts
stance phase, double support phase, and stance sharply with our present findings demonstrating
phase. Similar observations concerning the exten- an overall improvement in gait kinematics after
sion of stance and double support phases in knee arthroplasty, although the follow-up in the
severe knee arthritis, compared with healthy, present study did not extend beyond 6 months.
age-matched persons, have been made by other Noteworthy, the distinguishing factor between
authors (Harding et al. 2012; Kiss 2011; these studies was the lack of individual neuro-
Kiliçoğlu et al. 2010; Astephen et al. 2008). The muscular facilitation physiotherapy in the former
extension of double support may constitute a and its use in the latter study. Neuromuscular
compensatory mechanism aiming at supporting facilitation physiotherapy should, however,
body weight by both lower limbs and thus reduc- involve a therapist as according to Szöts et al.
ing the affected knee joint loading while walking. (2015), as many as 70% of patients admitted for
It also may lead to an increase in both stance elective knee joint arthroplasty do not regularly
8 J. Jaczewska-Bogacka and A. Stolarczyk

perform recommended exercises at home in the hip replacement patients – a large scale, long-term
first months after surgery. One of the advantages follow-up study. Gait Posture 28(2):194–200
Beswick AD, Wylde V, Gooberman-Hill R, Blom A,
of such is a significant reduction in pain percep- Dieppe P (2012) What proportion of patients report
tion during the time following knee arthroplasty, long-term pain after total hip or knee replacement for
which we noted in this study and which should osteoarthritis? A systematic review of prospective
not be underestimated. Post-surgery pain studies in unselected patients. BMJ Open 2(1):e000435
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