Adherence to total knee arthroplasty guidelines in Saudi physiotherapists

Alghamdi, Yazeed Abdulrahman; Aljulaymi, Ibrahim Saeed; Althumali, Faisal; Abdel-fattah, Mostafa S.; Dewir, Ibrahim M.

doi:10.1590/fm.2025.38123

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ORIGINAL ARTICLE • Fisioter. Mov. 38 • 2025 • https://doi.org/10.1590/fm.2025.38123 linkcopy

Adherence to total knee arthroplasty guidelines in Saudi physiotherapists

Adesão às diretrizes de artroplastia total do joelho em fisioterapeutas sauditas

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction Total knee arthroplasty (TKA) is a widely performed surgical procedure for managing advanced stages of knee osteoarthritis. Following clinical practice guidelines (CPGs) is essential to ensure optimal reha-bilitation outcomes.

Objective To evaluate the level of knowledge and compliance with evidence-based practice guidelines and recommendations related to TKA among physiotherapists in Saudi Arabia.

Methods An online cross-sectional survey was administered among licensed physiotherapists practicing in Saudi Arabia who had managed at least one patient undergoing TKA within the past two years. The questionnaire in-cluded demographic questions, two clinical vignettes (prehabilitation and acute postoperative rehabilitation), and statements assessing agreement with evidence-ba-sed recommendations (EBR). Adherence levels were ca-tegorized, and statistical associations with demographic variables were analyzed using chi-square and ANOVA tests.

Results The study included 391 physiotherapists (mean age: 31.5 ± 6.1 years), with males comprising 78% of the sample. Only 2 and 3% of participants fully adhered to the EBR in the prehabilitation and post-operative vignettes, respectively. Adherence was signi-ficantly associated with gender, years of experience, workplace setting, educational level, specialty, and the number of TKA cases managed (p < 0.05). Knowledge gaps were also evident in consensus statements, with less than half agreeing on the use of standardized outcome measures and postoperative management proto-cols.

Conclusion Adherence to TKA CPGs among Saudi physiotherapists is generally low. Experience, workplace setting, and professional background influence adherence. There is a need for targeted educational interven-tions and systemic support to improve evidence-based practice in TKA rehabilitation.

Total knee arthroplasty; Clinical guidelines; Evidence-based practice; Physiotherapy; Saudi Arabia

Clinical Scenario 1: Pre-habilitation before a total knee replacement

History: F.A. is a 64-year-old woman who was referred to a rehabilitation center 6 weeks before her total knee replacement, to be given a prehab program to both reduce surgery risk as well as lead to better post-surgery recovery.
Physical examination:
Altered gait (walking) pattern with a reduction in weight-bearing over the left knee
Standing on a slightly flexed left knee
Swelling and joint line thickening – ‘arthritic looking joint’
Wasting of the quadriceps muscle
Poor balance and proprioception
The range of motion is restricted to no more than 100 degrees of flexion without pain
Crepitus (noisy) knee joint and patella-femoral joint (knee cap) with flexion
Reduced muscle strength in the left leg
Poor core stability
Pain on palpation along the knee joint line
Positive special test for meniscal damage
Please choose from the following list which procedures you would implement to manage the patient in this scenario (more options available).
Reiteration of appropriate footwear, basic diet, and joint supplement advice
Ice therapy regularly, not just after exercises
Gentle cycling using a static cycle
Hydrotherapy (pool-based) exercises
Advice to the patient to contact the specialist or to go to the emergency room
Advice to the patient to contact the specialist or to go to the emergency room, starting in the meantime the rehabilitation program
Protection with a semi-rigid brace
Protection with a lace-up brace
Protection with elastic tape (kinesiotaping)
Manual therapy, including soft tissue massage and trigger point release around the quadriceps and back of the knee
Basic balance and proprioception exercises

Clinical scenario 2: Acute postoperative rehabilitation of total knee replacement

History: Mr. M was a keen sportsman as a young man, but started getting increasing problems with his knees with age. He therefore had a total knee replacement.
Physical examination: An initial examination 7 days after his surgery showed that Mr. M was able to mobilize with the aid of two sticks. He tended to keep his affected knee in a slightly bent position and was reluctant to take his full weight through the leg. His range of movement was reduced partially due to the excess swelling and weakness in his quadriceps.
Please choose from the following list which procedures you would implement to acutely manage the patient in this scenario (more options available).
Cryotherapy
Motor function training (balance, walking, movement, symmetry)
Postoperative knee range-of-motion exercise
Immediate postoperative knee flexion during rest for blood loss and swelling
Neuromuscular electrical stimulation
Resistance and intensity of strengthening exercise
Continuous passive motion device use for mobilization
Postoperative physical therapy supervision
Gentle cycling using a static cycle
Hydrotherapy (pool-based) exercises
Protection with a semi-rigid brace
Protection with a lace-up brace
Protection with elastic tape (kinesiotaping)

Variable	Not following (n = 168)	Partially following (n = 216)	Following (n = 7)	P-value	Effect size (r)
Age*	30.9 (6.0)	31.5 (6.0)	35.8 (1.0)	0.100±	η² = 0.015
Gender
Male	111 (66.1)	175 (81.0)	7 (100)	<0.001≠	V = 0.190
Female	57 (33.9)	41 (19.0)	0 (0.0)	<0.001≠	V = 0.190
Living region
Central	25 (14.9)	29 (13.4)	0 (0.0)	0.100≠	V = 0.129
Eastern	22 (13.1)	55 (25.5)	3 (42.9)
Western	88 (52.4)	98 (45.4)	4 (57.1)
Southern	22 (13.1)	26 (12.0)	0 (0.0)
Northern	11 (6.5)	8 (3.7)	0 (0.0)
Years of experience
1 – 5	119 (70.8)	112 (51.9)	0 (0.0)	<0.001≠	V = 0.190
6 – 9	27 (16.1)	40 (18.5)	4 (57.1)
≥ 10	22 (13.1)	64 (29.6)	3 (42.0)
Workplace
Ministry of Health hospitals	42 (25.0)	105 (48.6)	4 (57.1)	<0.001≠	V = 0.267
Primary health centers	7 (4.2)	9 (4.2)	0 (0.0)
University hospitals	19 (11.3)	21 (9.7)	0 (0.0)
Private rehab centers	79 (47.0)	67 (31.0)	0 (0.0)
Military hospitals	21 (12.5)	14 (6.5)	3 (42.9)
Highest education level
Diploma	11 (6.6)	18 (8.3)	3 (42.9)	0.001≠	V = 0.223
Bachelor’s	117 (69.6)	142 (65.7)	4 (57.1)
Some postgraduate	20 (11.9)	25 (11.6)	0 (0.0)
Master’s	17 (10.1)	24 (11.1)	0 (0.0)
PhD	3 (1.8)	7 (3.2)	0 (0.0)
Specialty
Neurology	21 (12.5)	24 (11.1)	0 (0.0)	<0.001≠	V = 0.288
Orthopedic	96 (57.1)	116 (53.7)	4 (57.1)
Geriatrics	4 (2.4)	12 (5.5)	0 (0.0)
Cardiothoracic	20 (11.9)	13 (6.0)	0 (0.0)
Pediatric	21 (12.5)	17 (7.87)	0 (0.0)
Oncology	0 (0.0)	16 (7.4)	0 (0.0)
Musculoskeletal	0 (0.0)	4 (1.85)	0 (0.0)
General	6 (3.6)	14 (6.5)	3 (42.9)
Number of TKA cases
1 – 5	92 (54.8)	102 (47.2)	4 (57.1)	0.008≠	V = 0.176
6 – 10	38 (22.6)	46 (21.3)	0 (0.0)
11 – 15	22 (13.1)	31 (14.3)	0 (0.0)
16 – 20	12 (7.1)	20 (9.3)	0 (0.0)
> 20	4 (2.4)	17 (7.9)	3 (42.9)

Variable	Not following (n = 185)	Partially not following (n = 89)	Partially following (n = 107)	Following (n = 10)	P-value	Effect size (r)
Age*	23.1 (7.6)	31 (4.0)	29.8 (3.5)	32.1 (3.4)	0.020±	η² = 0.041
Gender					0.500≠	V = 0.103
Male	148 (80.0)	64 (71.9)	82 (76.6)	5 (50.0)
Female	37 (20.0)	25 (28.1)	25 (23.4)	5 (50.0)
Living region
Central	33 (17.8)	12 (13.5)	9 (8.4)	0 (0.0)	0.010≠	V = 0.171
Eastern	33 (17.8)	22 (24.7)	21 (19.6)	4 (40.0)
Western	89 (48.1)	38 (42.7)	57 (53.3)	6 (60.0)
Southern	23 (12.4)	9 (10.1)	16 (15.0)	0 (0.0)
Northern	7 (3.8)	8 (9.0)	4 (3.7)	0 (0.0)
Years of experience
1 – 5	119 (64.3)	36 (40.4)	74 (69.2)	2 (20.0)	<0.001≠	V = 0.314
6 – 9	19 (10.3)	28 (31.5)	20 (18.7)	4 (40.0)
≥ 10	47 (25.4)	25 (28.1)	13 (12.1)	4 (40.0)
Workplace
Ministry of Health hospitals	77 (41.6)	34 (38.2)	30 (28.0)	9 (90.0)	<0.001≠	V = 0.327
Primary health centers	0 (0.0)	0 (0.0)	15 (14.0)	0 (0.0)
University hospitals	23 (12.4)	11 (12.3)	10 (9.4)	0 (0.0)
Private rehab centers	68 (36.8)	24 (27.0)	52 (48.6)	1 (10.0)
Military hospitals	17 (9.2)	20 (22.5)	0 (0.0)	0 (0.0)
Highest education level
Diploma	11 (6.0)	12 (13.5)	9 (8.4)	0 (0.0)	<0.001≠	V = 0.291
Bachelor’s	129 (69.7)	43 (48.3)	81 (75.7)	10 (100)
Some postgraduate	15 (8.1)	17 (19.1)	13 (12.2)	0 (0.0)
Master’s	27 (14.6)	10 (11.2)	4 (3.7)	0 (0.0)
PhD	3 (1.6)	7 (7.9)	0 (0.0)	0 (0.0)
Specialty
Neurology	32 (17.3)	7 (7.9)	6 (5.6)	0 (0.0)	<0.001≠	V = 0.316
Orthopedic	101 (54.6)	42 (47.2)	59 (55.1)	2 (20.0)
Geriatrics	4 (2.2)	0 (0.0)	12 (11.2)	4 (40.0)
Cardiothoracic	12 (6.5)	8 (9.0)	13 (12.2)	0 (0.0)
Pediatric	15 (8.1)	18 (20.2)	13 (12.2)	0 (0.0)
Oncology	8 (4.3)	8 (9.0)	0 (0.0)	0 (0.0)
Musculoskeletal	4 (2.2)	0 (0.0)	0 (0.0)	0 (0.0)
General	9 (4.8)	6 (6.7)	4 (3.7)	4 (40.0)
Number of TKA cases
1 – 5	110 (59.4)	38 (42.7)	52 (48.6)	5 (50.0)	<0.001≠	V = 0.264
6 – 10	31 (16.8)	20 (22.5)	34 (31.8)	1 (10.0)
11 – 15	14 (7.6)	20 (22.5)	17 (15.9)	4 (40.0)
16 – 20	8 (4.3)	11 (12.3)	0 (0.0)	0 (0.0)
> 20	22 (11.9)	0 (0.0)	4 (3.7)	0 (0.0)

	Statement about assessment	Agreement	Disagreement
Outcome assessment	Should PTs, at least at the first visit, incorporate outcome measures, such as KOOS JR, the 30-second sit-to-stand, and TUG as part of the physical assessment?	185 (47.3)	206 (52.7)
Management	Should PT management not start within 24 hours of surgery for patients who have undergone TKA? (Reversed statement)	165 (42.2)	226 (57.8)
	At least one of the following treatment modalities is strongly recommended in the rehabilitation program for patients who have undergone TKA: (A) Motor function training; (B) Neuromuscular electrical stimulation; (C) Strength training.	199 (50.9)	192 (49.1)
	Should PTs not implement a preoperative exercise program, including strengthening and flexibility exercises, and provide preoperative education for patients undergoing TKA? (Reversed statement)	172 (44.0)	219 (56.0)
	PTs should not provide guidance to the care team and to the patient on safe and objective discharge planning, patient functional status, assistive equipment, and services required to facilitate a safe discharge. (Reversed statement)	201 (51.4)	190 (48.6)
	PTs should develop an early mobility plan and teach patients who have undergone TKA regarding the importance of early mobility and appropriate progression of physical activity, based on safety, functional tolerance, and physiological response.	241 (61.6)	150 (38.4)
	PTs may use group-based or individual-based physical therapy sessions for patients who have undergone TKA.	207 (52.9)	184 (47.1)
Prognosis	PTs should not consider prognostic factors, such as BMI, tobacco use, comorbidities, physical, and psychological function during the management of patients who have undergone TKA. (Reversed statement)	74 (18.9)	317 (81.1)
Prognosis	Diabetes is not associated with less functional outcomes. (Reversed statement)	48 (12.3)	343 (87.7)

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[TFN1] Note: *Data presented as n (%), except for age: mean (standard deviation). ≠Pearson chi-square test. ±One-way ANOVA. p < 0.05 is considered statistically significant. Effect size (r): Cramér’s V for chi-square; η² for ANOVA. Interpretation of effect sizes: small ≈ 0.1, medium ≈ 0.3, large ≥ 0.5.

[TFN2] TKA = total knee arthroplasty.