, more than 
 84,000 primary total knee arthroplasty ( tka ) procedures were performed in the uk , according 
 to data from the national joint registry data1 . patients awaiting knee replacement surgery commonly experience 
 difficulty maintaining balance and functional status ; these problems further increase as the 
 waiting time for surgery lengthens2 . post - operative ( post - op ) physical therapy ( pt ) after tka has been identified as an 
 important factor for successful patient outcome . exercises are widely recommended after tka 
 to improve walking and activities of daily living3 . these include numerous interventions such as exercise , manual 
 techniques , knee taping , electrotherapeutic modalities , and education to implement patient 
 self - management strategies4,5,6 . however , the 
 evidence of the effects of pre - operative ( pre - op ) pt in this population is limited2 . two previous systematic reviews have 
 reported low to moderate quality evidence that pre - op supervised pt reduces pain in patients 
 with hip and knee osteoarthritis prior to joint replacement1 , 7 while , in contrast , another 
 study did not find a significant impact of pre - op pt plus education on range of motion , 
 muscle strength or post - op disability8 . in 
 addition , dauty et al . reported no benefit of pre - op and post - op pt in patients undergoing 
 tka9 . furthermore , in a systematic 
 review , silkman baker and mckeon10 did 
 not report positive effects of pre - op rehabilitation compared to other interventions in 
 individuals undergoing tka . there are very few studies that address this topic ; to the best of our knowledge , no study 
 has compared the effect of pre- and post - op pt versus post - op pt alone after tka especially 
 on pain and functional recovery . hence , we compared the effect of pre - op and post - op pt 
 versus only post - op pt on pain and recovery of function after tka . a prospective randomized rater - blinded trial with assessments at baseline , week 3 and week 
 6 post - op was used to compare the effect of pre - op and post - op pt ( pre - post pt ) and post - op 
 pt alone on pain and recovery of function after tka ( fig . 1.flow diagram of prospective randomized rater - blinded trial comparing pre- and 
 post - operative pt and post - operative pt only . all the participants gave written informed consent approved by the institutional 
 ethical committee ( iec ) . flow diagram of prospective randomized rater - blinded trial comparing pre- and 
 post - operative pt and post - operative pt only . pt : physical therapy fifty consecutive patients who underwent tka at primus super specialty hospital , new delhi , 
 india , participated in this study . they were randomly divided through the chit box method 
 into two groups ( 25 subjects in each group)11 . one group received pre - post pt whereas the other group received 
 only post pt . the inclusion criterion was a pre - operative diagnosis of primary knee 
 osteoarthritis ( oa ) by the orthopedic surgeon based on the american college of rheumatology 
 ( acr ) criteria12 . patients were excluded 
 if they had a history of rheumatoid arthritis , cognitive impairment , or ankylosing 
 spondylitis . pain and physical functioning were assessed by using the visual analogue scale ( vas ) and 
 the lower extremity functional scale ( lefs ) , respectively . the lefs is a 20-item questionnaire 
 designed to measure activity limitation of lower extremities and has an established validity 
 for measuring the lower extremity function in a population of patients with orthopedic 
 problems17,18,19 . each item of the lefs is 
 scored on a likert 5-point scale ranging from 0 to 4 . lefs scores range from 0 to 80 points , 
 with higher scores indicating a higher functional level19 . the lefs appears to recognize changes similar or superior to those 
 recognized by the womac physical function subscale in patients undergoing knee or hip 
 arthroplasty20 . while admitted to 
 the hospital before tka , all the patients in the pre - post pt group received daily pt 
 sessions of approximately 30 minutes duration . it included strengthening and mobility 
 exercises , proper techniques of transfers , and gait training with assistive devices ( stick 
 or walker ) . after discharge from the 
 hospital , the patients received 12 sessions of pt , twice a week for 6 weeks , comprised 
 mainly strengthening and mobility exercises as well as gait training . in addition , all the 
 patients received 20 minutes of conventional transcutaneous electrical nerve stimulation 
 ( tens ) to minimize pain . all the patients were instructed to repeat these exercises at home . 
 in the present study , data analysis was done by using ibm spss statistics 21 ( statistical package for the social sciences , ibm , inc . repeated measure analysis of variance ( anova ) 
 with bonferroni adjustments for multiple comparisons was used to study the changes in 
 dependent variables over time . univariate anova was used to compare the dependent variables 
 at each level between the two groups . fifty patients ( 18 males and 32 females ) who underwent tka agreed to participate in the 
 study . the differences in age and weight of two groups were found to be statistically 
 insignificant ( average age 63.53 vs. 66.55  years ; average weight 90.83 vs. 93.75  kg . ; tables 1table 1.comparison of vas score over time in each groupgroups pre - op3 weeks post - op6 weeks post - opmean  sdmean  sdmean  sdpre- and post - op pt8.9  0.94.7  1.3 * 1.9  1.4#post - op pt only8.7  1.04.1  1.6 * 2.4  1.3#vas : visual analogue scale ; sd : standard deviation ; pt : physical therapy . * difference 
 between preoperatively ( pre - op ) and week 3 , p<0.001 . difference between pre - op and week 6 post - op , p<0.001 and 2table 2.comparison of lefs score over time in each groupgroups pre - op3 weeks post - op6 weeks post - opmean  sdmean  sdmean  sdpre - and post - op pt18.9  10.128.6  11.455.9  15.9post - op pt only15.6  9.130.2  12.8 * 58.0  13.5#lefs : lower extremity functional scale ; sd : standard deviation ; pt : physical therapy . * difference between preoperatively ( pre - op ) and week 3 post - op functional score , 
 p<0.001 . # difference between week 3 post - op and week 6 post - op , p<0.001 . difference between pre - op and week 6 post - op , p<0.001 indicate intra - group comparison of the results . both groups showed 
 statistically significant reduction in pain intensity and improved functional score at the 
 end of the study ( p<0.05 ) . mean reduction of pain intensity in the pre - post pt group was 
 7 ; in the post - op pt group , it was 6.3 . mean improvement of functional score in the pre - post 
 pt group was 37 ; in the post - op pt group , it was 42.4 . post hoc analysis revealed 
 significant reduction of pain intensity among baseline , week 3 , and week 6 and between week 
 3 and week 6 ( p<0.01 ) in both groups . similarly , significant improvement in functional 
 score was noted among baseline , week 3 , and week 6 and between week 3 and week 6 ( p<0.01 ) 
 in the post - op pt group . however , non - significant improvement in functional score was noted 
 between baseline and week 3 and between week 3 and week 6 in the pre - post pt group 
 ( p>0.05 ) . a significant improvement in functional score was noted between baseline and 
 week 6 in the pre - post pt group ( p<0.001 ) . tables 
 3table 3.comparison of vas score between pre- and post - operative pt and post - operative pt 
 alonevariables pre- and post - op ptpost - op pt onlymean  sdmean  sdpre - op8.9  0.98.7  1.03 weeks post - op4.7  1.34.1  1.66 weeks post - op1.9  1.42.4  1.3vas : visual analogue scale ; sd : standard deviation ; pt : physical therapy and 4table 4.comparison of lefs score between the pre- and post - operative pt and the 
 post - operative pt onlyvariablespre - and post - op ptpost - op pt onlymean  sdmean  sdpre - op18.9  10.115.6  9.13 weeks post - op28.6  11.430.2  12.86 weeks post - op55.9  15.958.0  13.5lefs : lower extremity functional scale ; sd : standard deviation ; pt : physical 
 therapy indicate inter group results . there were statistically insignificant 
 differences in pain intensity and functional score between the pre - post pt and post - op pt 
 groups ( p>0.05 ) at baseline and at week 3 and week 6 post - op . vas : visual analogue scale ; sd : standard deviation ; pt : physical therapy . * difference between pre - op and week 6 post - op , p<0.001 lefs : lower extremity functional scale ; sd : standard deviation ; pt : physical therapy . * difference between preoperatively ( pre - op ) and week 3 post - op functional score , 
 p<0.001 . # difference between week 3 post - op and week 6 post - op , p<0.001 . difference between pre - op and week 6 post - op , p<0.001 vas : visual analogue scale ; sd : standard deviation ; pt : physical therapy lefs : lower extremity functional scale ; sd : standard deviation ; pt : physical 
 therapy the aim of this study was to compare the effect of pre - op and post - op pt versus post - op pt 
 alone on pain and recovery of function after tka . during the first post - op month , a 
 significant reduction in pain and improvements in physical function were reported in both 
 the groups . however , there was no difference between the two groups . in the available literature on efficacy of exercise in tka patients , most of the studies 
 have focused either only on pre - op or post - op exercises . similar to our study , previous studies have also questioned any additional benefit 
 of the addition of pre - op exercises in patients undergoing joint arthroplasty , especially 
 for the knee1 , 8 , 21 . neither a pt program to 
 strengthen upper or lower limb strength nor exercises to improve knee range of motion and 
 strength have been shown to add to the degree of improvement after tka2 , 22,23,24 . however , 
 targeted post - op care following pre - op assessments has been shown to decrease the length of 
 hospital stay25 . various studies have 
 reported its effect on decreasing pain and length of stay after surgery25 , 26 . most 
 of the available studies focused on pain reduction , strength gain , or mobility after knee 
 replacement surgeries . fewer studies have taken the quality of life , the return to work and 
 daily activities , or the physical functioning as a whole as outcome measures in such 
 studies . data on quality of life recovery after surgery plays an important role in deciding 
 the standard of care for patients28 . hence , along with pain reduction , we decided to include the lefs , which is a measure of 
 activity limitation . although pt has been shown to be very effective in the management of arthritis and its 
 prevention and progression29,30,31,32 , this study suggests that additional pre - op pt did not 
 bring about any further improvement in pain intensity or function after tka . the reduction 
 of pain and recovery of function were similar in subjects who received pre - op and post - op pt 
 and those who received only post - op pt after tka . the average hospital stay was 5 days ; therefore , the number of sessions 
 received during pre - op pt might not have been enough to bring about a significant change in 
 the outcome . in addition , there was no follow - up after 6 weeks ; therefore , the long - term 
 effects of these interventions remain unclear . in the future study , in addition to pain and 
 function , the assessment of the quadriceps and hamstring muscle strength , knee range of 
 motion , and the gait parameters is warranted . in conclusion , the reduction of pain and recovery of function were similar in subjects who 
 received pre- and post - op pt and those who received only post - op pt after tka . additional 
 pre - op pt did not bring about any further improvement in pain intensity and function after 
 tka .
[ purpose ] the aim of the present study was to compare the effect of pre - operative and 
 post - operative physical therapy versus post - operative physical therapy alone on pain and 
 recovery of function after total knee arthroplasty . [ subjects and methods ] fifty patients 
 ( 18 males and 32 females ) ranging in age from 48 to 80  years ( mean 63.28 , sd 9.44 ) 
 participated in a 6-week two - arm randomized rater - blinded trial . 
 one group received pre- 
 and post - operative physical therapy whereas the other group received only post - operative 
 physical therapy . 
 pain and function were measured with a visual analogue scale and a lower 
 extremity functional scale at baseline ( pre - operative ) as well as week 3 and week 6 
 post - operative . 
 [ results ] the differences in pain intensity and functional score at week 3 
 and week 6 post - operative remained statistically insignificant between the two groups . 
 [ conclusion ] the reduction of pain and recovery of function was similar in subjects who 
 received pre- and post - operative physical therapy and those who received only 
 post - operative physical therapy after total knee arthroplasty . 
 additional pre - operative 
 physical therapy did not bring about any further improvement in pain intensity or recovery 
 of function after total knee arthroplasty .