Q: My doctor told me after my total knee replacement, I won't need any special therapy or rehab. My sister who lives in a different state told me she had a special exercise program they called "functional." She says the reason she is doing so well is because they pushed her not to be afraid to move. Do I need that program too?

A: Each surgeon has his or her own post-operative "protocol" (way of doing things) after a total knee replacement. Physiotherapy is an important part of the immediate post-operative period. Once you are discharged to go home, some surgeons may insist on a short-term follow-up period with your therapist. But not everyone needs a full-blown functional exercise program.

Those who can benefit from a more tailored rehab program may be folks who were more fearful about movement before surgery. Their level of pain caused them to start avoiding certain movements and activities at home and work. This pattern of behavior is called fear-avoidance. People who become fearful of movement are said to be kinesiophobic.

This pattern of pain-related fear does not automatically go away after the joint is replaced. That's why physiotherapy is needed to restore full motion and function without the element of fear preventing recovery and return to all activities. Functional exercises is a popular way to achieve these goals.

Functional exercises refers to a type of program designed to do more than just regain 90-degrees of knee flexion or lift the leg off the bed ten times. Functional exercise-based rehabilitation programs are geared toward improving motion and strength while preventing blood clot formation and while restoring specific activities. Walking; climbing stairs; and making sudden starts, stops, and turns are just a few examples of the skills functional exercises work to restore.

If you are kinesiophobic (e.g., unwilling to go out shopping or to run a few errands, afraid to go for a walk, feel uncertain about returning to work), you might benefit from some coaching. The physiotherapist will show you how to practice physical activities and movements at home. You will be encouraged to perform all these things without fear. The goal of therapy is to increase activities previously considered "dangerous" (i.e., before surgery).

It is possible to pre-identify (before surgery) patients whose recovery from a total knee replacement may be compromised by fear-avoidance thinking and behaviors. Education and exercise can help correct these behaviors and aid patients in overcoming barriers to full recovery. Addressing and treating kinesiophobia in this way puts the burden of responsibility for recovery from mistaken beliefs and thoughts squarely on the patient's shoulders.

Be sure and bring this question up to your surgeon before the procedure is scheduled. Working out all the details ahead of time can speed up your recovery and may help prevent ongoing disability.

Reference: Marco Monticone, MD, PhD, et al. Home-Based Functional Exercises Aimed at Managing Kinesiophobia Contribute to Improving Disability and Quality of Life of Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial. In Archives of Physical Medicine. February 2013. Vol. 94. No. 2. Pp. 231-239.

In Balance Physiotherapy provides services for physiotherapy in Toronto.