Keywords

10.1 Introduction

In 2013, Weinstein et al. [1] calculated that 655,800 total knee arthroplasty (TKA) recipients in the USA were 50–59 years old and 984,700 patients were 60–69 years old, indicating a large number of individuals that were expected to be active in fitness and recreational activities. Subsequent studies showed a disproportionate increase in the percentage of younger individuals (under the age of 60 years) requiring TKA [2, 3]. This appears to be especially true in individuals that participate in recreational activities over their lifetime who developed knee osteoarthritis (OA) [4,5,6] and in patients who sustain athletic injuries such as anterior cruciate ligament (ACL) ruptures that underwent meniscectomy [7,8,9,10,11,12].

TKA is performed in many athletes, as well as individuals who wish to resume a physically active lifestyle after surgery. These patients have high preoperative expectations [13,14,15] that correlate strongly with postoperative patient satisfaction [14, 16, 17], as detailed in Chap. 12. Therefore, the assessment of which recreational activities are resumed postoperatively is important to determine for preoperative patient counseling and a goal-oriented rehabilitation program to accomplish patient expectations. In addition, objective measurement of the level of physical activity (PA) using validated activity monitors provides realistic data regarding changes in parameters such as percent of time spent in sedentary behaviors compared with light, moderate, or vigorous activities; step counts; time spent walking; distance achieved; and so on. Finally, the determination of whether symptoms of pain and/or swelling occur with recreational activities is also important to assess the ability of TKA to return patients to an active lifestyle, including aerobic fitness, and achieve high levels of satisfaction. This chapter represents an update of the authors’ previous systematic review [18] of this topic in published literature through October 2020.

10.2 Current Physical Activity Guidelines for Healthy Adults

In 2018, the American Heart Association (AHA) updated its guidelines for OA for healthy individuals (Table 10.1) [19, 20]. The guidelines were based on the work of a 17-member advisory committee that extensively reviewed the literature on PA and health [21]. Evidence was rated as strong, moderate, limited, or not assignable and was based on risk factors for cardiovascular disease that can be modified by PA, including blood pressure, blood glucose, blood lipids, and body weight.

Table 10.1 Examples of aerobic physical activities and intensities for adultsa
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Recommendations for substantial health benefits for all healthy adults (aged ≥18) were at least 150–300 minutes of moderate-intensity PA a week, or 75–150 minutes of vigorous-intensity activity, or an equivalent combination of moderate- and vigorous-intensity activity. During moderate-intensity activity, a person can talk but not sing. During vigorous-intensity activity, a person cannot say more than a few words without pausing to catch their breath. In addition, muscle-strengthening exercises of moderate or greater intensity that involve all major muscle groups should be performed at least 2 days a week. Adults aged ≥65 years were also encouraged to do multicomponent PA that includes balance training. They were advised to determine their level of effort for PA according to their l evel of fitness and whether any chronic conditions were present.

The guidelines allow for a cumulative effect of PA throughout the week. Therefore, the first recommendation was that “adults should move more and sit less throughout the day. Some physical activity is better than none.” Therefore, sedentary patients who begin to perform some PA, such as taking the stairs or parking further from a store, could be expected to achieve some benefits.

The 2018 CDC Physical Activity Guidelines [22] further defined activity in terms of metabolic equivalents (METs) , which is the most commonly used unit to measure PA. One MET is the rate of energy expenditure while sitting at rest, 1.3 for sitting and reading, 2.0 for walking slowly, 3.3 for walking at 3 miles per hour, and 8.3 for running at 5 miles per hour. Vigorous-intensity activity requires >6.0 METs; moderate-intensity activity, 3.0 to <6.0; light-intensity activity, 1.6 to <3.0; and sedentary activity ≤1.5. PA is also reported in terms of frequency (sessions of moderate-to-vigorous PA per day or week), duration (length of each session), and intensity (in METs). Volume is calculated in MET minutes or MET hours per day or week. The use of personal devices (pedometers and accelerometers) to measure PA allows for volume to be expressed as activity counts or step counts during a period of time.

10.3 Sports and Recreational Activities After TKA

We assessed data from 21 studies that detailed recreational and sports activities patients participated in postoperatively (Table 10.2) [23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43]. The studies reported a wide range of patients that returned to recreational activities (25–100%, Fig. 10.1). The mean percentages of patients that participated in the most common activities including walking, bicycling (stationary or road), hiking, swimming, dancing, fitness training or classes such as aerobic or aquatic, and golf are shown in Fig. 10.2. Evidence was not routinely available regarding the number of sports patients participated in on a weekly basis, although some studies indicated patients took part in more than one sports activity [27, 38, 40]. Frequency of participation was highly variable due to the differing methods reported that included the number of days/week [25, 38], number of days/month [36], mean hours/week [28, 32, 43], mean minutes/week [33], and mean number of times per week any activity was performed [39, 40] (Table 10.3).

Table 10.2 Studies that determined sports and recreational activity after TKA
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Fig. 10.1
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The overall percent of TKA patients that returned to sports and recreational activities per study. These data were not available for five of the 20 studies

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Fig. 10.2
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The most common sports and recreational activities reported after TKA. Only studies that reported multiple activities were included. The number of studies for each activity was: walking 8, bicycling 13, hiking 8, swimming 13, dancing 7, fitness/classes 8, and golf 9

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Table 10.3 Sports and recreational activities after TKA
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Only a few studies described symptoms or limitations that occurred with activity [36, 38, 43, 44]. A “major limitation” during participation was found in 14% in one study [44]. Pain in the knee was reported during activity in 16% in one study [43] and in 17% in another (while golfing) [36]. One investigation [38] reported that 26% of patients had pain in their knee and 26% had a feeling of instability during participation. Factors responsible for the inability to return to PA were usually other musculoskeletal problems or persistent pain in the TKA joint [23, 31, 37, 38, 43].

Factors that influenced return to recreational activities included higher preoperative levels of activity [23, 26, 27], higher educational level [24], male gender [37], and body mass index less than 30 [37]. Most studies found that younger patient age at TKA led to higher postoperative activity levels (<70 years [37], <65 years [33], or “younger” age [26]). There were significant correlations found between University of California at Los Angeles (UCLA) activity scores and SF-36 and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in one study [29], and between patient activity levels (high, medium, and low impact) and Knee Injury and Osteoarthritis Outcome Score (KOOS) sports, KOOS quality of life, and WOMAC scores in another study [28].

Although the majority of studies that reported return to activity data following TKA found the majority participated in low-impact activities [45], a few described patients who returned to high-impact sports. However, an analysis of symptoms or limitations with these activities has not been rigorously conducted to our knowledge. For instance, Mont et al. [39] followed a cohort of 31 patients (who represented 4% of their TKA population) that returned to sports that involved running and other high-impact activities a mean of 4 years postoperatively. All but one had excellent clinical outcomes and were satisfied with the result of the operation. The authors stressed their opinion that these types of activities were not appropriate for the majority of patients. However, with a small percentage choosing to return, surgeons should work closely to individualize recommendations. Mayr et al. [28] found that 25% of 81 patients who lived in an Alpine area returned to high-impact activities such as downhill skiing and tennis, and 47% returned to medium-impact sports such as mountain hiking and cross-country skiing. All but one patient had been involved in sports during their lifetime. While most patients were participating in low-impact activities at the 1-year evaluation, the evaluation at 6 years showed increased involvement in higher-impact sports. Hepperger et al. [25] reported that 74% of 200 patients from Austria returned to hiking and 70% returned to downhill skiing 2 years postoperatively. These authors attributed the results to living in the Alpine region and noted that the home geographic environment plays an important role in activities resumed postoperatively.

10.4 Objective Measured Physical Activity After TKA

Eight studies measured movement-related activity, three of which determined the percent of patients who achieved AHA recommended PA guidelines (Table 10.4) [46,47,48,49,50,51,52,53]. At 6 months postoperatively, two studies reported that 0% [47] to 18% [46] met the guidelines, and at 12 months postoperatively, one study [48] found that 16.5% met the guidelines. There was wide variability in study conclusions regarding time spent in sedentary behavior compared with preoperative data, as four studies reported no change [47,48,49, 51] and three studies reporting a significant decrease [46, 50, 52]. Postoperative PA levels were considerably lower than those of healthy controls in one study [48] and were lower than previously published data in another study [50].

Table 10.4 Studies that determined physical activity after TKA
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It is important to note that in normal adult populations, investigators have shown that only a small percentage of adults meet AHA guidelines. Whether the data from TKA studies and those from control populations regarding problems achieving PA guidelines are strictly related to aging or are due to other factors such as socioeconomic status and motivation is unclear and worthy of future study. One investigation that measured PA in 2450 healthy adults aged 70–93 years reported that only 15% of men and 10% of women achieved >150 minutes a week of PA [54]. Another study of 3459 US adults aged 49–85 years measured PA for 7 days and reported that only 2.5% achieved adherence of PA guidelines of ≥30 min/day of moderate-to-vigorous movement intensity [55].

In a systematic review of 26 studies that measured PA levels after total joint (hip and knee) arthroplasty (using either objective instruments or recall questionnaires), Naal and Impellizzeri [56] reported noteworthy heterogeneity and provided recommendations to standardize future studies. They noted patients undergoing total joint arthroplasty were less active than recommended AHA levels. Accelerometers provide realistic data of all types of activity (light, moderate, and vigorous) and give feedback and motivation to patients [57]. Total daily step count is a beneficial motivator, and Garber et al. [58] recommended ≥7000 steps/day, which could be achieved by increasing step counts by ≥2000 as necessary to achieve this level. In 2018, Hammett et al. [59] systematically reviewed the literature for studies that only used accelerometers from preoperative to postoperative from inception of the PubMed database to January 2016 for TKA and total hip arthroscopy. Seven studies were included, four of which focused on TKA, and the authors found no significant increase in PA at 6 months (compared with preoperative) and only a small to moderate effect at 12 months.

Clinical studies usually employ patient self-reporting of activity levels with questionnaires such as the UCLA activity scale [60]. These data are not always reliable, may be subject to recall bias [51, 61], and may overestimate PA compared with objective activity measurements [47, 50, 51]. For example, Harding et al. [47] reported no change in PA parameters 6 months after TKA measured with an accelerometer in 25 patients. However, there was a significant increase in the UCLA activity scores between the preoperative and follow-up evaluations (3 ± 1 and 5 ± 3, respectively; P < 0.001). Brandes et al. [50] also reported no correlation between PA and clinical outcomes as measured with the Knee Society Score and SF-36.

10.5 Recommended Sports and Recreational Activities

At the time of writing, the most recent activity recommendations following TKA by the American Association of Hip and Knee Surgeons were published in 2009 (Table 10.5) [62]. Based on the results of 139 completed surveys from the 2007 annual meeting, consensus was reached for low-impact activities such as walking, climbing stairs, bicycling on level surfaces, swimming, doubles tennis, and golfing. Activities that were consistently discouraged included jogging, sprinting, skiing on difficult terrain, and singles tennis. A survey of 94 surgeons from the Netherland Orthopaedic Association included 40 sports, of which the surgeons indicated whether they were allowed, allowed with experience, discouraged, or no opinion [63]. The results for patients <65 years of age are shown in Table 10.5. For patients >65 years of age, the same activities achieved consensus for allowed and not allowed as the younger group. Two additional activities reached consensus for allowed with experience (cross-walking and rowing). A systematic review of 21 studies published from 1986 through 2010 by Vogel et al. [64] provided advice regarding the most appropriate activities after TKA. These authors stressed the avoidance of sports that create high-impact loads and noted that rehabilitation may take at least 3 months to allow low-impact activities.

Table 10.5 Survey activity recommendations after TKA
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10.6 Authors’ Discussion

Important goals of TKA in younger active patients include maintaining a healthy lifestyle and returning to desired realistic recreational or sports activities. However, in patients who wish to resume moderate- or high-intensity recreational and sports activities after TKA, the high loads placed on the knee joint may result in chronic effusions and muscle dysfunction.

There was a wide range of patients that resumed mostly light, low-impact recreational activities after TKA (25–100%). There are many potential reasons for lack of postoperative participation in recreational activities or PA, including lingering effects of the operation (pain or swelling), the natural aging process, income, educational status, area of residency, personal barriers and beliefs, self-efficacy, and social support [65,66,67,68]. The reasons patients elect not to participate in recreational activities after TKA are important to determine, especially in studies in which return to PA is a main focus. Five studies reported that the factors most commonly responsible for the inability to return to PA were other musculoskeletal problems or persistent pain in the TKA joint [23, 31, 37, 38, 43].

Few studies provided data regarding symptoms or functional limitations that occurred during recreational or sports activities. For patient counseling purposes, future studies should provide these data to ensure that preoperative patient expectations are realistic in terms of activities that are resumed after surgery. Finally, no study provided detail regarding the postoperative rehabilitation program. This book describes in detail the role of the physical therapist in guiding a patient back to recreational or fitness activities. Rehabilitation programs that incorporate strength, balance, flexibility, and neuromuscular function have been recommended to safely resume PA [69,70,71]. Objective assessment of muscular and neuromuscular function prior to release to activities is also recommended [72,73,74,75]. A careful balance of joint loads must be managed to reduce chronic knee joint effusions (which is an indicator of the need to reduce activities) and chronic muscle weakness.