Effectiveness of an Integrated Multimodal Physiotherapy Rehabilitation Program on Proprioception, Quadriceps Strength, Gait Parameters, Pain, and Functional Outcomes After Total Knee Replacement: A Randomized Controlled Trial

Abstract

Background: Post-operative recovery after total knee replacement (TKR) remains challenging, with persistent deficits in proprioception, quadriceps weakness, altered gait mechanics, and chronic pain affecting quality of life in up to 20% of patients.

Objective: To evaluate the effectiveness of an integrated multimodal rehabilitation program combining neuromuscular training, sensorimotor training, functional strengthening, and pain neuroscience education compared to standard post-operative care on proprioception, quadriceps strength, gait parameters, pain, and functional outcomes in patients undergoing TKR.

Design: Randomized controlled trial.

Methods: Ninety participants scheduled for primary TKR were randomly allocated to either an integrated multimodal program (n=45) or standard care control group (n=45). The multimodal intervention consisted of 24 supervised sessions delivered twice weekly over 12 weeks, incorporating structured neuromuscular training, proprioceptive retraining on variable surfaces, progressive functional strengthening with emphasis on closed kinetic chain exercises, and two sessions of pain neuroscience education. Primary outcomes included Knee Injury and Osteoarthritis Outcome Score (KOOS) pain and activities of daily living subscales. Secondary outcomes comprised quadriceps isometric strength, 6-minute walk distance, proprioceptive error measured by joint position sense testing, gait velocity and cadence, and pain intensity on the Visual Analog Scale. Assessments were conducted at baseline, 3, 6, 9, and 12 weeks post-operatively.

Results: At 12 weeks, the multimodal group demonstrated significantly greater improvements in KOOS pain (78.6±14.2 vs 68.2±16.4, p=0.031), KOOS ADL (82.3±12.8 vs 71.6±15.3, p=0.024), quadriceps strength (1.84±0.42 vs 1.52±0.38 Nm/kg, p=0.018), 6-minute walk distance (541.2±98.6 vs 472.8±104.3 meters, p=0.012), and proprioceptive error reduction (2.6±1.2 vs 3.8±1.6 degrees, p=0.042) compared to standard care. Pain reduction was significantly greater in the multimodal group (VAS 2.1±0.8 vs 3.2±1.1, p=0.019). Gait velocity improved more substantially in the multimodal group (1.24±0.28 vs 1.08±0.26 m/s, p=0.028).

Conclusion: An integrated multimodal physiotherapy program delivered in the early post-operative period significantly enhances functional recovery following total knee replacement, with particular benefits for proprioceptive restoration, pain management, and lower limb strength development. The incorporation of neuromuscular training, sensorimotor components, functional strengthening, and pain education appears to synergistically improve post-operative outcomes.

Keywords: Total Knee Replacement; Rehabilitation; Proprioception; Neuromuscular Training; Pain Neuroscience Education; Randomized Controlled Trial; Gait; Functional Outcomes

Citation

P. Muthukrishnan, S. Rajadurai. Effectiveness of an Integrated Multimodal Physiotherapy Rehabilitation Program on Proprioception, Quadriceps Strength, Gait Parameters, Pain, and Functional Outcomes After Total Knee Replacement: A Randomized Controlled Trial. WebLog J Phys Ther Rehabil. wjptr.2025.l2001. https://doi.org/10.5281/zenodo.18058033