gonarthrosis is one of the most common arthrotic involvements developing due to a 
 degenerative process in the skeletal system1 . it is not possible to stop the degenerative process despite the 
 presence of many treatment alternatives . the total knee arthroplasty is the gold 
 standard2 for reducing pain , healing 
 deformities and restoring stability in patients who progress to the terminal stage2,3,4 . arthroplasty is a commonly accepted treatment method in degenerative diseases of the knee 
 and the hip with excellent outcomes shown in the last 1520 years5 , 6 . components of 
 motion of knee joint are hurt from in arthroplasty applications as in every operation 
 affecting skeletal system . physiotherapy techniques are the most important tools that 
 patients and doctors have for rapidly regaining functional status . rehabilitation programs 
 including supervised physical therapy7 or 
 home exercises are recommended for restoring functional status in patients after knee 
 arthroplasty8 , 9 . supervised physical therapy two or three times a week recently , interest has been increasing regarding investigation and evaluation of the causes 
 of increasing health costs10 . effort has 
 been focused on studies about cost - effectiveness analysis and controlling costs11 . increased cost of health care leads to 
 critical investigations concerning the effectiveness of treatment and needs in physiotherapy 
 and rehabilitation methods . the main purpose of 
 this study was to prospectively compare the short- and long - term outcomes of supervised 
 physiotherapy and a standardized home program following discharge of patients who underwent 
 tka and to evaluate the effectiveness and costs of postoperative rehabilitation . this study was conducted in accordance with the principles of the helsinki declaration 
 ( 2008 ) . it was conducted after ethics committee approval had been obtained from the 
 pamukkale university medical faculty ( ref no.08 , date : 28.05.2013 ) . patients who underwent total knee arthroplasty between january 2009 and june 2011 were 
 randomly divided to two groups , a supervised physiotherapy ( sp ) group and standardized home 
 program ( hp ) group , using a random number table . surgical opening , the arthroplasty technique ( extramedullary guide , ligament - preserving 
 type of arthroplasty , etc . ) , incision closure and wound care were performed in a standard 
 manner in all patients . all 
 patients were mobilized after their drainage tubes had been removed postoperatively , and a 
 continuous passive motion ( cpm ) device was applied beginning with 45 degrees of knee flexion 
 and continuing with 60 degrees on day 2 , 90 degrees on day 3 and 110 degrees on days 4 and 
 5 . strengthening exercises were applied for the thigh abductor , adductor , extensor and 
 quadriceps femoris muscles with active aid , and active joint motions twice daily under 
 supervision of the physiotherapist until discharge from the hospital . patients were 
 mobilized with a walker so that they could bear as much weight as was tolerable on the 
 arthroplasty side 24 hours after the operation . after discharge , patients in the home program were controlled for exercises once weekly for 
 4 weeks and rearranged by the physiotherapist when needed . patients ( home program group ) 
 performed home exercise for an hour a day , five days a week , for four weeks . home exercises 
 included arrangement of knee joint motion limit , restoration of knee and hip muscle power . patients in supervised physiotherapy participated in a total of 20 sessions of a 
 physiotherapy and rehabilitation program 5 days a week for 4 weeks . this program included 
 knee joint range of motion ( rom ) exercises and strengthening exercises for the knee and hip 
 following 20  min of application of moist heat , and 20  min of conventional transcutaneal 
 electrical nerve stimulation ( tens ) application . all participants were evaluated by a different physiotherapist , that is , not the one 
 applying the therapy program . descriptive data of the participants were collected using a descriptive data questionnaire . 
 a 10  cm visual analogue scale consisting of a straight vertical line the patients were instructed that  0  represented  no pain  and that  10  represented  the 
 most severe pain  . the patients were then asked to mark their level of pain on the line , and 
 the distance to the point they marked was measured using a ruler and recorded12 . range of motion ( rom ) was evaluated using a universal goniometer , and measurements were 
 evaluated using the rom degrees defined by kendall13 . the western ontorio and mcmaster universities osteoarthritis index ( womac ) was used for 
 assessment of functional status . the reliability and validity of the turkish index composed 
 of 24 questions were tested by tzn et al . in 200514 . the index was scored on likert scale ranging between 0 and 4 , with 
  0  indicating  no  and  4  indicating  very severe  . the results were evaluated out of 100 
 points , with  100  meaning  healthy  and  0  meaning  very poor15 . the 
 reliability and validity of the turkish adaptation of the scale were tested by hisli et al . , 
 and the cutoff value was determined to be 1716 . the short form 36 ( sf-36 ) , which was developed by the rand corporation , was used for 
 assessment of overall quality of life17 . the subscales are used to evaluated health 
 by transforming them to scales ranging between 0100 , with  0  indicating  poor health  and 
  100  indicating a  good health status  . these subscales are reported to be usable for 
 assessment of quality of life in patients who have physical diseases18 . patient were asked to complete the scale on their 
 own . the statistical package for the social sciences ( spss ) version 16.0 was used for 
 statistical analysis . descriptive statistical data are presented as means  standard 
 deviation ( x  sd ) or percentages ( % ) . the kolmogorov - smirnov test was used to determine whether data 
 met parametric test conditions . the superiority of the demographic data obtained before the 
 study was evaluated with the independent samples t - test in independent groups . the paired 
 samples t - test was applied in dependent groups to determine the effectiveness of the methods 
 used in the study . the independent samples t - test was used to determine the superiority of 
 applications in independent groups19 . the mean age of the patients was 64.253.86  years in the sp group and 68.086.25  years in 
 the hp group . other descriptive data of the patients are given in table 1table 1.descriptive data of the patientsvariables supervised physiotherapy groupstandardized home program group 
 ( n=16)min  maxxsdmin  maxxsdage ( years)606864.253.86617968.086.25height ( cm)154158155.751.70155168161.173.35weight ( kg)6610485.7517.015010374.8313.81bmi ( kg / m)26.4443.8535.447.6019.5340.6228.815.37educational status ( yr)555.000.000123.913.50n%n%gender * female 1688.91593.8male 211.116.2job * housewife1688.91593.8self - employed15.616.2retired teacher 15.6 - -*statistically significant ( p < 0.05 ) . * statistically significant ( p < 0.05 ) clinical improvements were observed in postoperative assessments in both groups . data 
 recorded in different control periods are given in table 2table 2.comparison of outcomes before and after the operation in supervised physiotherapy 
 groupvariables supervised physiotherapy group 
 ( n=18)results causing differencesbefore the operation3 mo6 mo1 year2 yearsxssxssxssxssxsspain ( vas ) rest 5.302.950.330.590.000.000.440.511.110.471 - 2,1 - 3,1 - 4,1 - 5,2 - 4,3 - 4,3 - 5,4 - 5activity9.250.941.831.501.772.393.111.960.830.781 - 2,1 - 3,1 - 4,1 - 5,4 - 5rom ( )flexion 72.3828.9585.277.37108.8315.26102.509.88112.783.071 - 3,1 - 4,1 - 5,2 - 3,2 - 5,4 - 5extension16.339.712.722.883.337.662.774.600.381.641 - 2,1 - 3,1 - 4,1 - 5,2 - 5functional status ( womac ) 67.3813.1527.2715.5815.387.2217.7217.516.226.891 - 2,1 - 3,1 - 4,1 - 5,2 - 5,3 - 5,4 - 5beck depression scale16.449.857.502.509.221.439.446.836.163.271 - 2,1 - 5,3 - 5overall quality of life scale ( sf-36)overall health status45.6122.3077.836.1155.8326.8032.5023.552.7722.301 - 2,2 - 3,2 - 4,2 - 5physical status15.7214.3842.7715.0763.0516.6355.5523.1974.7214.591 - 2,1 - 3,1 - 4,1 - 5,2 - 3,2 - 5emotional status56.2223.8260.1815.0550.2018.3151.2216.2474.227.902 - 5,3 - 5,4 - 5social status51.2228.8347.1610.8968.6116.0154.8323.8882.508.171 - 5,2 - 3,2 - 5,4 - 5physical role limitation1.385.8911.1032.330.000.0044.4451.1377.7837.261 - 4,1 - 5,2 - 5,3 - 4,3 - 5emotional role limitation33.4445.7058.7729.1427.5636.3577.7842.7794.4323.571 - 5,2 - 5,3 - 4,3 - 5pain 16.7216.6853.166.4159.0112.6865.7233.6363.4715.071 - 2,1 - 3,1 - 4,1 - 5energy level44.5527.6753.335.6852.223.9140.5523.6371.6610.981 - 5,2 - 5,3 - 5,4 - 5*variance analysis in repeated measurements . 5=1  year 
 after the operation for the sp group and in table 
 3table 3.comparison of developments before and after the operation in home exercise 
 programvariables standardized home program group 
 ( n=16)measurements causingdifferencesbefore the operation3 mo6 mo1 year2 yearsxsdxsdxsdxsdxsdpain ( vas)rest 5.153.840.000.000.120.340.370.800.000.001 - 2,1 - 3,1 - 4,1 - 5activity7.963.091.681.530.560.752.501.771.000.001 - 2,1 - 3,1 - 4,1 - 5,3 - 4,4 - 5rom (  ) flexion 92.6818.0090.1210.65106.9112.74103.1220.64113.759.391 - 5,2 - 3,2 - 5extension13.2515.771.562.390.621.701.874.030.000.001 - 3,1 - 5functional status ( womac ) 54.8714.9325.0014.0515.6211.3411.259.396.626.061 - 2,1 - 3,1 - 4,1 - 5,2 - 3,2 - 4,2 - 5,3 - 4,3 - 5beck depression scale11.125.877.185.295.503.145.755.544.505.661 - 3,1 - 5overall quality of life scale ( sf-36)overall health status59.6819.3678.186.1573.4315.2464.3717.4064.0612.801 - 2,2 - 4,2 - 5physical status28.7514.7749.3727.5074.3723.3771.2525.2685.932.801 - 3,1 - 4,1 - 5,2 - 5emotional status60.2514.7187.0117.0081.2510.9063.0219.1874.756.141 - 2,1 - 3,1 - 5,2 - 4,3 - 4social status61.3729.5448.1218.5075.5625.7281.8120.2888.591.281 - 5,2 - 4,2 - 5physical role limitation0.000.0062.5050.0071.8740.6987.5034.1557.8138.421 - 2,1 - 3,1 - 4,1 - 5emotional role limitation12.4329.4062.4951.0081.1229.9087.5134.1562.5034.151 - 2,1 - 3,1 - 4,1 - 5pain 23.1218.4643.871.5073.4024.4052.0617.5654.213.841 - 2,1 - 3,1 - 4,1 - 5,2 - 3,2 - 5energy level48.4318.0463.122.5065.6216.2156.2516.5868.437.681 - 3,1 - 5*variance analysis in repeated measurements . 5=1  year 
 after the operation while there was not a statistically significant difference in activity pain of the patients 
 in both groups , assessments of resting pain were found to be statistically significantly 
 different in month 3 ( p=0.032 ) and after 2  years ( p=0.00 ) in favor of the hp group . no 
 statistically significant difference was detected at each assessment point when rom and 
 functional status of the patients were compared . when depressive symptoms of the patients in 
 both groups were compared at different assessment points , a statistically significant 
 difference was detected in the hp group in only the month 6 assessments ( p=0.000 ) . when the 
 overall qualities of life of the patients were compared , a statistically significant 
 difference was detected in favor of the hp group in all subparameters except emotional 
 status , physical role limitation , pain , and energy level in month 3 and in all subparameters 
 except physical status and social status in month 6 . a statistically significant difference 
 was detected in favor of the hp group in all subparameters except physical status , emotional 
 role limitation , and pain after 1  year , and a significant difference was detected in favor 
 of the hp group in physical status and social status and in favor of the sp group in 
 emotional role limitation , pain , and overall quality of life parameters ( table 4table 4.differences between supervised physiotherapy and the standardized home 
 programvariablesbefore theoperation3 mo6 mo1 year2 yearstttttpain ( vas)rest0.1282.240*1.5560.3039.412*activity1.6760.2791.9480.9450.847rom()flexion2.417*1.5580.3971.3310.415extension0.6951.2661.3800.6040.941functional status ( womac)2.589 * 0.4410.0731.3170.180beck depression scale1.8800.0150.019 * 0.0411.064overall quality of life scale ( sf-36)overall health status1.9530.1682.313*4.491*1.778physical status 2.602*0.8811.6411.8892.364*emotional status0.5845.684*5.904*2.103*0.215social status1.0130.1870.9573.526*2.943*physical role limitation0.9413.599*7.508*2.848 * 1.537emotional role limitation1.5712.2694.656*0.7263.204*pain1.0625.653*2.196 * 1.4562.383*energy level0.4786.354*3.403*2.214 * 0.981*statistically significant ( p < 0.05 ) , independent samples t - test ) . * statistically significant ( p < 0.05 ) , independent samples t - test a cost analysis was performed for physical therapy and rehabilitation services following 
 tka . the total costs were 508.6 tl for the sp group and 299.40 tl for the hp group . the home 
 exercise program reduced spending for health ( physiotherapy and rehabilitation applications ) 
 ( table 5table 5.cost analysis of physiotherapy and rehabilitation treatments in the physiotherapy 
 and home program groups ( based on 2013 health practices notification prices)applications physiotherapygroup ( tl ) home programgroup ( tl ) preoperative assessment 15.5015.50weekly postoperative control-93.00 ( 15.506)assessment at 1 month post operation 15.5015.50physical therapy outpatient clinic examination15.5015.50physical therapy outpatient clinic assessment15.5015.50treatment parameterswarm heat application2.40-tens application2.40-rom exercises4.804.80progressive resistance exercises3.603.60total price of the session 264 ( 13.2020)50.40 ( 8.406)outpatient clinic examination after 10 sessions15.50-outpatient clinic examination after 20 sessions15.50-assessment at 3 months post operation 15.5015.50assessment at 6 months post operation15.5015.50assessment at 1 year post operation15.5015.50assessment at 2 years post operation15.5015.50transportation fee ( round trip)89.60 ( 3.2028)32.00 ( 3.2010)total cost508.60299.40tens : transcutaneous electrical nerve stimulation . total knee arthroplasty ( tka ) is a quite effective method for treatment of knees with 
 severe degenerative arthritis not treated with other treatment methods20 , and the number of patients undergoing tka has been 
 gradually increasing in our country as in other countries throughout the world in recent 
 years21 . surgeons direct their patients to physiotherapy following surgical intervention due to loss 
 of motion of the joint , accessory movement , quadriceps muscle atrophy , tissue edema , and 
 walking , stability , pain , balance , and functional limitations22 , 23 . physiotherapy and 
 rehabilitation are usually recommended to help patients become functionally independent 
 following knee surgery and to help them return to their pre - disease conditions . supervised 
 physiotherapy two or three times weekly is a commonly preferred method of achieving these 
 goals7 , 24 . today , the increased cost of health care and the sector becoming 
 open to competition naturally increase the interest of economists and politicians in cost 
 analysis , and cost - effectiveness calculations have begun to be performed for every 
 application in health25 . cost - effectiveness studies for evaluation and determination of the causes of increasing 
 costs play an effective role in controlling expenditures10 , 12 , 26 . increased health - care costs bring critical analysis for 
 cost - effectiveness in physiotherapy applications together . some studies have focused on home 
 exercise , and home exercises have been shown to be as effective as supervised physical 
 therapy8 . there has been no study in our 
 country determining the needs for physiotherapy and rehabilitation following hospital 
 discharge after tka , comparing supervised physiotherapy and rehabilitation and standardized 
 home programs , and performing cost analyses fort he programs . therefore , we planned to 
 compare the functional outcomes and costs of a standardized home program and supervised 
 physiotherapy . while many studies are available in the literature comparing supervised rehabilitation and 
 a standardized home program following anterior crucial ligament repair , there are very few 
 studies about tka . the available studies indicate that there is no significant difference 
 between patients treated with supervised physiotherapy and those treated with a standardized 
 home exercise program with respect to range of motion of the knee joint , functional status 
 of the patient , and overall health status of the patient8 , 27 , 28 . in our study , this comparison was performed for patients who were 
 followed up for a minimum of 2  years prospectively . while a statistically significant 
 difference was not detected in most of the parameters , a significant difference was detected 
 in some parameters in different assessment periods in favor of the hp group , and there was 
 only a statistically significant difference in favor of the sp group in the emotinal role 
 limitation and pain subparameters of the overall quality of life scale , but only at the 
 2-year assessments . in the assessments , statistically significant differences were usually 
 observed between the two groups in the overall quality of life subscales . the cost analysis performed in the present study was based on the health practices 
 notification ( hpn ) published by social security institution in 2013 . the total cost of 
 rehabilitation was determined to be 508.60 tl in the sp group and 299.40 tl in the hp group 
 according to official prices of the hpn . the cost of treatment in the sp group was almost 
 twice that in the hp group , although there was no difference between the treatment 
 applications in terms of outcome even though there was a significant difference in favor of 
 the hp group in some parameters . patients with tka experience some difficulties when they benefit from physical therapy and 
 rehabilitation outpatient clinic services . in addition , delay of treatment due to crowded 
 clinics and inadequate physical conditions leads to delays in rehabilitation programs for 
 patients and loss of motivation in patients . considering the economic burden of health care , 
 we consider that it would be sufficient to instruct patients on how to perform a 
 well - planned home exercise program and to have a physiotherapist perform regular 
 follow - ups .
[ purpose ] the aim of this study was to determine the functional differences between total 
 knee arthroplasty ( tka ) patients who were treated with supervised physiotherapy or a 
 standardized home program and perform a cost analysis . 
 [ subjects and methods ] patients who 
 received total knee arthroplasty between january 2009 and june 2011 were enrolled in this 
 study ; those with mean ages of 64.253.86 ( 6068 ) years ( n=18 ) and 68.086.25 ( 6179 ) 
 years ( n=16 ) were placed in the supervised physiotherapy and standardized home program 
 groups , respectively . 
 all patients were evaluated by the same researcher before and after 
 surgery , and the therapy programs were applied by another physiotherapist . 
 all patients 
 were evaluated for joint range of motion ( rom ) , pain , functional status ( womac ) , overall 
 quality of life ( sf-36 ) , and depressive symptoms ( beck depression scale ) . 
 [ results ] a 
 significant clinical improvement was observed in postoperative assessments . 
 a 
 statistically significant difference could not be found between rom and functional levels 
 of the patients in both groups . 
 [ conclusion ] no difference was found between the patients 
 performing supervised or standardized home program with respect to the effects on 
 functional status . 
 a home exercise program can be used in the rehabilitation of patients 
 with tka , and implementation of home exercise programs can also reduce health - care 
 spending .