Right approach and PHYSIOTHERAPY protocol after TKR

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"total knee replacement" AND "physiotherapy" AND "rehabilitation"

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PMID: 40635148

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physiotherapy rehabilitation protocol after total knee replacement TKR phases exercises 2024

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https://www.sportssurgeryclinic.com/wp-content/uploads/2021/…

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https://www.royalberkshire.nhs.uk/media/ww5bknsi/advice-and-…

I now have comprehensive information to construct a detailed, evidence-based physiotherapy protocol after TKR. Let me compile the full answer.

Physiotherapy After Total Knee Replacement (TKR): Right Approach & Protocol

Overview of Principles

Physiotherapy is the cornerstone of TKR recovery. The goals are to:

Control pain and swelling
Restore full knee extension (most critical - must be achieved early)
Regain adequate flexion (≥110° for functional activities)
Strengthen quadriceps and lower limb musculature
Restore normal gait pattern
Return to independent activities of daily living

A 2025 systematic review of 19 RCTs (Aftab et al., Musculoskeletal Care 2025) confirmed that early physiotherapy significantly improves pain relief, ROM, and quality of life - with strengthening programs and early mobilisation showing the strongest outcomes.

PRE-OPERATIVE PHASE (Prehabilitation)

Although evidence shows only modest benefit from prehabilitation (Cureus 2024 review), the following are still recommended:

Patient education: Explain post-op expectations, demonstrate exercises, show walking aids
Strengthening: Quadriceps sets, straight leg raises, hip abductor strengthening
ROM exercises: Achieve and maintain full pre-op ROM
Cardiovascular conditioning: Walking, cycling, hydrotherapy if available
Optimize medical comorbidities: BMI, DM, cardiovascular status

POST-OPERATIVE REHABILITATION: PHASE-BASED PROTOCOL

PHASE 1 - Acute Phase: Day 0 to 2 Weeks

Key Goals:

ROM: 0-90° (aim to improve from discharge ROM)
Straight leg raise with minimal/no quadriceps lag
Safe independent transfers
Independent mobilisation with walking aid
Pain and swelling well controlled
Safe on stairs

Day 0 (Day of Surgery):

Get the patient UP on the day of surgery
Frame initially, progressed to crutches once safe
Discharge when independent on stairs and safe with crutches (may be same day)

Exercises (begin Day 1, 5-10 reps, 2x/day):

Exercise	Technique
Static Quads (Quad sets)	Lie flat, push back of knee into bed, pull toes up, hold 5-10 sec
Straight Leg Raise (SLR)	Tighten quads, lift leg ~2 inches, hold 5-10 sec
Inner Range Quads	Towel rolled under knee, straighten knee lifting heel, hold 5-10 sec
Full Range Quads	Sitting on chair/bed, extend knee fully, hold 10 sec
Static Gluteals	Tighten buttock muscles, hold 5-10 sec
Knee Flexion in Sitting	Bend knee as far as possible, hold 8-10 sec
Ankle Pumps	Dorsiflexion/plantarflexion - continuous, every waking hour (DVT prevention)
Foot Circles	Circular ankle movements
Heel Slides	Lying flat, slide heel toward buttock

Pain/Swelling Management:

Ice 20 minutes, 3-4x/day, towel protection
Elevation above heart level when resting
Manual lymphatic drainage shown to reduce swelling (Meta-analysis, BMC Musculoskelet Disord 2024 - PMID 38167036)
Continue prescribed analgesics and anti-inflammatories

Gait Training:

Full weight-bearing as tolerated with frame/crutches
Progress crutches → one crutch/stick → unaided

Extension is Priority: Never allow a flexion contracture to develop. Use towel under heel (not under knee) when resting to passively extend.

PHASE 2 - Intermediate Phase: Weeks 2 to 6

Key Goals:

ROM: 0-110°+
SLR without quadriceps lag
Mobilising independently at home; walking aid outdoors only
Pain/swelling decreased but may persist
Independent on stairs (step-to pattern progressing to reciprocal)
Beginning balance and proprioception training

Exercises:

Exercise	Notes
Short Arc Quads	Towel under knee, extend from ~30° to full extension
Hamstring Isometrics	Progress to concentric/eccentric
Heel Raises	Bilateral first, progress to single leg
Sit to Stand	From progressively lower chairs
Mini Squats	To 30-45°, ensure correct alignment
Step-ups	Begin with low step (10 cm), progress height
Step-downs (eccentric)	Control descent
Aggressive Flexion ROM	Passive, active-assisted, active - sitting and supine
Extension ROM	Prolonged low-load stretching (prone hang or heel on roll)

Manual Therapy:

Patellar mobilisations (superior-inferior and medial-lateral glides) - critical for flexion ROM
Soft tissue massage to quadriceps, hamstrings, gastrocnemius
Scar massage (from 2-3 weeks post-op, once wound healed): circular movements, change direction frequently

Balance/Proprioception:

Tandem stance, single-leg balance (with support initially)
A 2026 systematic review (Dominguez-Navarro et al., Disabil Rehabil 2026) confirmed balance and proprioceptive training shows immediate significant benefits on balance outcomes after TKR

⚠️ Key Precaution: Pain should NOT persist beyond 24 hours after a physiotherapy session. If it does, reduce intensity. Monitor wound healing at every session.

PHASE 3 - Strengthening Phase: 6 Weeks Onwards

Key Goals:

Maximise and maintain knee ROM
Maximise lower limb strength
Normal gait without walking aid
Reciprocal stair pattern
Floor-to-stand transfers (with assistance)
Graduated return to work

Exercises:

Exercise	Notes
Leg Press	Low range initially, increase load progressively
Terminal Knee Extension (TKE)	Theraband resistance
Stationary Cycling	Excellent for ROM and endurance; begin when flexion ≥90°
Step Machine / Stair climbing	Reciprocal pattern
Wall Slides / Partial Squats	0-60° initially
Lateral Band Walks	Hip abductor/external rotator strengthening
Single-Leg Balance	Unaided, progress to unstable surface
Hip Strengthening	Abduction, extension, external rotation
Treadmill Walking	Speed progression

Neuromuscular Electrical Stimulation (NMES):

NMES to quadriceps helps in early strengthening when voluntary contraction is difficult
Evidence supports use in the early post-operative period

Aquatic Therapy:

Start when wound is fully healed (typically 6-8 weeks)
Warm water reduces pain, buoyancy reduces joint load
Allows earlier progression of functional exercises
Particularly beneficial for obese or elderly patients

PHASE 4 - Advanced Functional Phase: 3-6 Months

Key Goals:

Full functional independence
Return to driving (typically 6 weeks if right knee, 3 months if left knee - check with surgeon)
Return to work (office work: 6-8 weeks; physical work: 3-6 months)
Return to recreational activities

Permitted/Encouraged Activities:

Walking (unlimited distance, flat terrain then hills)
Swimming, cycling, golf
Ballroom dancing
Low-impact fitness activities

Activities to Avoid (generally for life after TKR):

High-impact sports (running, jumping, contact sports)
Activities involving kneeling for prolonged periods (manage with kneeling pad if needed)
Single-leg high-load pivoting sports

ROM TARGETS (Key Milestones)

Timeframe	Flexion Target	Extension Target
Day 1-2	60-70°	0° (full)
2 weeks	90°+	0°
6 weeks	110°+	0°
3 months	120-130°	0°
Final (1 year)	120-135°	0° (no deficit)

Critical: Full extension (0°) is more important than flexion. A flexion contracture of even 5° causes abnormal gait and accelerates implant wear.

SPECIAL MODALITIES

Modality	Evidence	Recommendation
Continuous Passive Motion (CPM)	Not proven to improve long-term ROM	Not routinely recommended; may be used early for ROM in selected cases
NMES/EMS	Good evidence for quadriceps strengthening	Recommended especially if SLR lag persists
Cryotherapy/Ice	Reduces swelling and pain	Yes, routinely
Manual Lymphatic Drainage	2024 meta-analysis supports use	Recommended for swelling management
Telerehabilitation	2024 SR (PMID 38574249) shows effectiveness comparable to in-person for elderly	Viable for maintenance phase or remote patients
Aquatic Therapy	Good evidence, especially for obese patients	After wound healing
Multidisciplinary Approach	2025 SR (PMID 40770481) shows reduces kinesiophobia vs. routine PT alone	Recommended to address fear-avoidance

ADDRESSING KINESIOPHOBIA (Fear of Movement)

A major barrier to recovery is kinesiophobia - fear of pain and re-injury. A 2025 SR (PMID 40770481) found multidisciplinary complementary interventions (education, cognitive-behavioral approaches + PT) significantly reduce kinesiophobia vs. routine physiotherapy alone.

Key strategies:

Education: explain what is safe vs. not after TKR
Graded exposure to feared movements
Reassurance that appropriate pain during exercise is expected and normal
Pain science education

DISCHARGE CRITERIA FROM PHYSIOTHERAPY

A patient can be discharged from active physiotherapy when they:

Walk without a walking aid on all surfaces
Can climb/descend stairs with reciprocal pattern
Have achieved functional ROM (minimum flexion 110°, full extension)
Can perform all ADLs independently
Have a home exercise program they can continue independently

COMPLICATIONS TO MONITOR

Stiffness/arthrofibrosis: Inadequate early mobilisation; requires aggressive PT or manipulation under anaesthesia
DVT/PE: Ankle pumps, early ambulation, pharmacological prophylaxis
Wound problems: Never perform vigorous massage over unhealed wound
Periprosthetic infection: Monitor for fever, erythema, excessive warmth
Patellar problems: Check patellar tracking, mobilise patella if restriction noted
Quadriceps lag: Persistent inability to SLR; indicates quadriceps insufficiency - intensify strengthening

Key sources: Sports Surgery Clinic TKR Rehabilitation Guidelines; Royal Berkshire NHS Post-TKR Exercise Protocol (Nov 2024); Aftab et al. Musculoskeletal Care 2025 (systematic review of 19 RCTs); Dominguez-Navarro et al. Disabil Rehabil 2026 (balance training meta-analysis); Lu et al. BMC Musculoskelet Disord 2024 (lymphatic drainage meta-analysis); Campbell's Operative Orthopaedics 15th Ed 2026; Miller's Review of Orthopaedics 9th Ed.

As a physio day 1 what I do

Here's your Day 1 (first post-operative day) physiotherapy session as a treating physio, laid out in the order you'd actually do it:

Day 1 Post-TKR: Physiotherapist's Action Plan

On Arrival — Assess First

Before touching the patient:

Review the notes: surgical approach, implant type, any intra-op complications, analgesia given, drain status, DVT prophylaxis started
Check vitals: BP, HR, SpO2, temperature
Pain score: VAS/NRS - ideally patient should be at 4/10 or below before you start
Wound check: Look for excessive bleeding through dressing, drain output
Limb check: Colour, warmth, sensation, pedal pulses - rule out vascular compromise
Swelling: Note baseline - compare both limbs
Current position of leg: Is the knee resting in extension or flexion? Correct flexion posture immediately - place a firm pillow/roll under the heel, NOT under the knee

Step 1 - Respiratory Exercises (5 min)

Often overlooked on Day 1 but mandatory, especially in elderly:

Deep breathing exercises: 5 deep breaths, hold 3 sec, exhale slowly - 10 reps
Huffing/coughing to clear secretions
This also doubles as general alerting/warming up the patient

Step 2 - Bed Exercises (Start Here - in lying)

Do these with the patient in supine. Start operated leg, then bilateral.

1. Ankle Pumps

Dorsiflexion + plantarflexion rhythmically
20-30 reps continuously
Purpose: DVT prophylaxis, venous return - this is your top priority

2. Foot Circles

Circumduction at ankle, both directions
10 circles each way

3. Quad Sets (Static Quadriceps)

Push back of knee down into bed, pull toes up, hold 5-10 sec
10 reps
Most important strengthening exercise on Day 1 - establishes quad control

4. Static Gluteal Squeezes

Squeeze buttocks together, hold 5-10 sec
10 reps

5. Inner Range Quads

Place a firm rolled towel under the knee (~30° support)
Ask patient to lift heel off bed, straighten the knee fully
Hold 5 sec, lower slowly
10 reps
Tests quad ability; expect this to be weak/painful on Day 1

6. Straight Leg Raise (SLR)

Tighten quads first, then raise leg to ~30-45°, hold 3-5 sec
Lower slowly
5-10 reps
If there is a significant quad lag (leg drops before it rises), note it - don't force it
Even an attempt is acceptable on Day 1

7. Heel Slides

Lying flat, slide heel toward buttocks as far as comfortable
Aim for ~60-70° flexion on Day 1
10 reps
Do NOT push into pain - gentle ROM is the goal

8. Hip Abduction in Lying

Slide operated leg out to the side and back
10 reps
Maintains hip abductor tone, prevents adductor tightness

Step 3 - Sitting Out of Bed (Transfer Training)

One of the most important things you do on Day 1 is get the patient sitting up and then standing.

Sit to edge of bed:

Lower the bed height
Log-roll technique or assisted rise
Dangle legs at edge - check for orthostatic hypotension (wait 1-2 min before standing)

Once sitting:

Gravity-assisted knee flexion (let the leg hang - aim 70-80° passively with gravity)
Active knee flexion/extension in sitting (foot on floor, slide back and forward)
Hold flexion at end range 10-15 sec

Step 4 - Standing and Gait Training

First stand-up:

Use a Zimmer frame (walking frame) - both hands
Ensure footwear is on (non-slip)
Nurse or assistant on the other side
Stand up: push from armrests/bed, do NOT pull on frame
Allow patient to stabilise - check for dizziness

Standing exercises (at frame):

Knee extension in standing (small knee bend then straighten)
Weight shift side to side
Single brief weight acceptance through operated limb

First walk:

Frame → step pattern: frame forward, operated leg forward, good leg forward
Short distance initially (to end of bed and back)
Watch for: antalgic gait, hip hitch, lack of heel strike, knee hyperextension
Correct gait deviations in real time

Stair assessment (if planned discharge on Day 1 or 2):

"Up with the good, down with the bad" - teach this rule
Good leg goes up first; operated leg goes down first
One step at a time initially

Step 5 - Ice and Elevation

After exercises:

Apply ice pack (with towel barrier) to knee - 15-20 min
Elevate the limb - heel propped, knee straight
Reassess pain score
Check wound dressing post-exercise (note any increased soakage)

Step 6 - Patient Education (Critical)

Before you leave, tell the patient:

What to Do	What NOT to Do
Ankle pumps every waking hour	Do NOT put a pillow under the knee
Keep leg elevated when in bed	Do NOT sit with knee hanging in flexion for long periods
Ice 3-4x per day	Do NOT force flexion into severe pain
Try to achieve full extension actively	Do NOT miss exercises
Report any calf pain, chest pain, sudden breathlessness	Do NOT bear weight without walking aid

What to Document

Pain score before and after session
ROM achieved: extension (is it 0°? Any lag?) and flexion (degrees)
Quad lag present/absent
SLR: achieved/not achieved
Distance walked, walking aid used, gait quality
Any concerns: wound, vascular, neurological
Patient compliance and understanding
Plan for Day 2

Realistic Expectations on Day 1

Parameter	Typical Day 1 Finding
Flexion ROM	60-80°
Extension	May have 5-10° lag initially - aim to correct
SLR	Often with lag or not possible - acceptable
Walking distance	Few metres to end of ward
Pain	Moderate - 4-6/10 even with analgesia

Red Flags - Stop and Escalate If:

Sudden drop in BP on standing (>20 mmHg systolic)
Calf swelling, pain, redness - suspect DVT
Chest pain, SOB, desaturation - suspect PE
Excessive wound bleeding post-session
Foot drop or loss of sensation - nerve injury
Extreme pain disproportionate to movement - check with surgical team

The single most important thing you achieve on Day 1 is getting the patient standing and walking, and establishing quad control. Everything else builds on this.

Generate a patient education handout for post-TKR home exercises

Reading File

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ls -la /tmp/workspace/ 2>/dev/null || mkdir -p /tmp/workspace && echo "workspace ready"

Running Command

mkdir -p /tmp/workspace/tkr-handout && cat > /tmp/workspace/tkr-handout/create_handout.py << 'PYEOF' from docx import Document from docx.shared import Pt, Inches, RGBColor, Cm from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.enum.table import WD_TABLE_ALIGNMENT, WD_ALIGN_VERTICAL from docx.oxml.ns import qn from docx.oxml import OxmlElement import copy doc = Document() # ── Page margins ────────────────────────────────────────────────────────────── section = doc.sections[0] section.page_width = Inches(8.27) # A4 section.page_height = Inches(11.69) section.top_margin = Cm(1.8) section.bottom_margin = Cm(1.8) section.left_margin = Cm(2.0) section.right_margin = Cm(2.0) # ── Colour palette ─────────────────────────────────────────────────────────── BLUE_DARK = RGBColor(0x00, 0x4E, 0x9A) # header / banner BLUE_MID = RGBColor(0x00, 0x7B, 0xC2) # section headings BLUE_LIGHT = RGBColor(0xD6, 0xEB, 0xF7) # table header fill ORANGE = RGBColor(0xE8, 0x6A, 0x1A) # warning / red-flag accent GREEN = RGBColor(0x2E, 0x7D, 0x32) # "do" items WHITE = RGBColor(0xFF, 0xFF, 0xFF) GREY_LIGHT = RGBColor(0xF4, 0xF6, 0xF8) # ── Helper: set cell shading ───────────────────────────────────────────────── def shade_cell(cell, hex_color): tc = cell._tc tcPr = tc.get_or_add_tcPr() shd = OxmlElement('w:shd') shd.set(qn('w:val'), 'clear') shd.set(qn('w:color'), 'auto') shd.set(qn('w:fill'), hex_color) tcPr.append(shd) def set_cell_border(cell, **kwargs): tc = cell._tc tcPr = tc.get_or_add_tcPr() tcBorders = OxmlElement('w:tcBorders') for edge in ('top','left','bottom','right'): tag = OxmlElement(f'w:{edge}') tag.set(qn('w:val'), kwargs.get('val', 'single')) tag.set(qn('w:sz'), kwargs.get('sz', '4')) tag.set(qn('w:color'), kwargs.get('color', 'auto')) tcBorders.append(tag) tcPr.append(tcBorders) def para_space(doc, before=0, after=0): p = doc.add_paragraph() pf = p.paragraph_format pf.space_before = Pt(before) pf.space_after = Pt(after) return p def add_section_heading(doc, text, color=BLUE_MID): p = doc.add_paragraph() pf = p.paragraph_format pf.space_before = Pt(10) pf.space_after = Pt(4) run = p.add_run(text.upper()) run.bold = True run.font.size = Pt(12) run.font.color.rgb = color # bottom border under heading pPr = p._p.get_or_add_pPr() pBdr = OxmlElement('w:pBdr') bottom = OxmlElement('w:bottom') bottom.set(qn('w:val'), 'single') bottom.set(qn('w:sz'), '6') bottom.set(qn('w:space'), '2') bottom.set(qn('w:color'), '%02X%02X%02X' % (color.red, color.green, color.blue)) pBdr.append(bottom) pPr.append(pBdr) return p def add_exercise_row(table, num, name, position, instructions, reps, freq): row = table.add_row() cells = row.cells # Number p = cells[0].paragraphs[0] run = p.add_run(str(num)) run.bold = True run.font.size = Pt(10) run.font.color.rgb = WHITE p.alignment = WD_ALIGN_PARAGRAPH.CENTER shade_cell(cells[0], '%02X%02X%02X' % (BLUE_MID.red, BLUE_MID.green, BLUE_MID.blue)) cells[0].vertical_alignment = WD_ALIGN_VERTICAL.CENTER # Exercise name + position p2 = cells[1].paragraphs[0] r = p2.add_run(name + '\n') r.bold = True r.font.size = Pt(10) r.font.color.rgb = BLUE_DARK r2 = p2.add_run('Position: ' + position) r2.font.size = Pt(8.5) r2.font.color.rgb = RGBColor(0x66, 0x66, 0x66) r2.italic = True # Instructions p3 = cells[2].paragraphs[0] r3 = p3.add_run(instructions) r3.font.size = Pt(9) # Reps p4 = cells[3].paragraphs[0] r4 = p4.add_run(reps) r4.font.size = Pt(9) r4.bold = True p4.alignment = WD_ALIGN_PARAGRAPH.CENTER # Frequency p5 = cells[4].paragraphs[0] r5 = p5.add_run(freq) r5.font.size = Pt(9) p5.alignment = WD_ALIGN_PARAGRAPH.CENTER # Alternate row shading if num % 2 == 0: for c in cells[1:]: shade_cell(c, 'F4F6F8') else: for c in cells[1:]: shade_cell(c, 'FFFFFF') # ═══════════════════════════════════════════════════════════════════════════════ # HEADER BANNER # ═══════════════════════════════════════════════════════════════════════════════ banner_table = doc.add_table(rows=1, cols=1) banner_table.alignment = WD_TABLE_ALIGNMENT.CENTER cell = banner_table.cell(0, 0) shade_cell(cell, '004E9A') p = cell.paragraphs[0] p.alignment = WD_ALIGN_PARAGRAPH.CENTER p.paragraph_format.space_before = Pt(10) p.paragraph_format.space_after = Pt(2) r = p.add_run('🦵 HOME EXERCISE PROGRAMME') r.bold = True r.font.size = Pt(18) r.font.color.rgb = WHITE r.font.name = 'Arial' p2 = cell.add_paragraph() p2.alignment = WD_ALIGN_PARAGRAPH.CENTER p2.paragraph_format.space_before = Pt(0) p2.paragraph_format.space_after = Pt(10) r2 = p2.add_run('After Total Knee Replacement (TKR) Surgery') r2.font.size = Pt(13) r2.font.color.rgb = RGBColor(0xCC, 0xE4, 0xFF) r2.font.name = 'Arial' # ── Patient info row ────────────────────────────────────────────────────────── info_table = doc.add_table(rows=1, cols=4) info_table.alignment = WD_TABLE_ALIGNMENT.CENTER shade_cell(info_table.cell(0,0), 'D6EBF7') shade_cell(info_table.cell(0,1), 'FFFFFF') shade_cell(info_table.cell(0,2), 'D6EBF7') shade_cell(info_table.cell(0,3), 'FFFFFF') labels = ['Patient Name:', '', 'Date of Surgery:', ''] for i, lbl in enumerate(labels): cell = info_table.cell(0, i) p = cell.paragraphs[0] p.paragraph_format.space_before = Pt(4) p.paragraph_format.space_after = Pt(4) run = p.add_run(lbl) run.bold = True run.font.size = Pt(9) run.font.color.rgb = BLUE_DARK para_space(doc, before=4, after=0) # ── Intro box ───────────────────────────────────────────────────────────────── intro_tbl = doc.add_table(rows=1, cols=1) shade_cell(intro_tbl.cell(0,0), 'EBF5FF') set_cell_border(intro_tbl.cell(0,0), val='single', sz='6', color='007BC2') ip = intro_tbl.cell(0,0).paragraphs[0] ip.paragraph_format.space_before = Pt(6) ip.paragraph_format.space_after = Pt(6) ir = ip.add_run( 'These exercises are an essential part of your recovery. ' 'Do them every day. They reduce swelling, restore movement, ' 'strengthen your muscles, and help you return to normal activities. ' 'If any exercise causes severe pain that does not settle within 30 minutes, ' 'stop and contact your physiotherapist.' ) ir.font.size = Pt(9.5) ir.font.color.rgb = BLUE_DARK ir.font.name = 'Arial' para_space(doc, before=4, after=0) # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 1 — WEEK 1-2 EXERCISES # ═══════════════════════════════════════════════════════════════════════════════ add_section_heading(doc, '📅 Week 1–2: Starting Exercises (Begin Day After Surgery)') p_note = doc.add_paragraph() p_note.paragraph_format.space_before = Pt(2) p_note.paragraph_format.space_after = Pt(4) rn = p_note.add_run('Start with 5 repetitions, 2× per day. Increase to 10 reps, 3-4× per day as pain allows.') rn.font.size = Pt(9) rn.font.color.rgb = RGBColor(0x44, 0x44, 0x44) rn.italic = True # Exercise table ex_table = doc.add_table(rows=1, cols=5) ex_table.style = 'Table Grid' # Header row hdr_cells = ex_table.rows[0].cells headers = ['#', 'Exercise', 'How To Do It', 'Reps', 'Times/Day'] widths = [Cm(0.9), Cm(3.8), Cm(7.5), Cm(1.8), Cm(2.0)] for i, (hdr, w) in enumerate(zip(headers, widths)): cell = hdr_cells[i] shade_cell(cell, '004E9A') p = cell.paragraphs[0] p.alignment = WD_ALIGN_PARAGRAPH.CENTER r = p.add_run(hdr) r.bold = True r.font.size = Pt(9) r.font.color.rgb = WHITE cell.width = w cell.vertical_alignment = WD_ALIGN_VERTICAL.CENTER exercises_wk12 = [ (1, 'Ankle Pumps', 'Lying or sitting. Bend your foot up toward you, then point it down. Keep moving rhythmically.', '30 reps', 'Every hour'), (2, 'Quad Sets\n(Static Quads)', 'Lying flat. Push the back of your knee DOWN into the bed. Pull toes toward you. Hold 10 sec. Feel the thigh tighten.', '10 reps', '4× day'), (3, 'Straight Leg Raise (SLR)', 'Tighten thigh (as above). Keeping knee STRAIGHT, lift leg 6 inches off bed. Hold 5 sec. Lower slowly.', '10 reps', '3-4× day'), (4, 'Inner Range Quads', 'Place a firm rolled towel under your knee (about 30°). Lift your heel off the bed by straightening the knee fully. Hold 5 sec.', '10 reps', '3-4× day'), (5, 'Heel Slides', 'Lying flat. Slide your heel toward your bottom as far as comfortable. Hold 5 sec. Slide back.', '10 reps', '3-4× day'), (6, 'Static Glute Squeeze', 'Lying flat. Squeeze both buttock muscles together tightly. Hold 10 sec. Relax.', '10 reps', '3-4× day'), (7, 'Knee Extension\n(Full Range)', 'Sitting on chair. Pull toes up, tighten thigh and STRAIGHTEN the knee fully. Hold 10 sec. Lower slowly.', '10 reps', '3-4× day'), (8, 'Knee Flexion\nin Sitting', 'Sitting on edge of chair/bed. Bend the knee as far back as comfortable. Hold 8-10 sec. Repeat. Use good leg to gently assist if needed.', '10 reps', '3-4× day'), ] for ex in exercises_wk12: add_exercise_row(ex_table, *ex) # ─ Extension tip ───────────────────────────────────────────────────────────── para_space(doc, before=4, after=0) ext_tbl = doc.add_table(rows=1, cols=1) shade_cell(ext_tbl.cell(0,0), 'FFF3E0') set_cell_border(ext_tbl.cell(0,0), val='single', sz='6', color='E86A1A') ep = ext_tbl.cell(0,0).paragraphs[0] ep.paragraph_format.space_before = Pt(5) ep.paragraph_format.space_after = Pt(5) er1 = ep.add_run('⚠️ IMPORTANT: ') er1.bold = True er1.font.size = Pt(9.5) er1.font.color.rgb = ORANGE er2 = ep.add_run( 'Always rest with a firm pillow or roll under your HEEL — never under your knee. ' 'Full straightening (extension) of your knee is the most important early goal. ' 'A bent knee that does not straighten fully causes long-term walking problems.' ) er2.font.size = Pt(9.5) er2.font.name = 'Arial' para_space(doc, before=6, after=0) # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 2 — WEEKS 2-6 # ═══════════════════════════════════════════════════════════════════════════════ add_section_heading(doc, '📅 Weeks 2–6: Progressive Exercises') p_note2 = doc.add_paragraph() p_note2.paragraph_format.space_before = Pt(2) p_note2.paragraph_format.space_after = Pt(4) rn2 = p_note2.add_run('Continue all Week 1-2 exercises AND add the following. Aim for 10 reps each, 3× per day.') rn2.font.size = Pt(9) rn2.font.color.rgb = RGBColor(0x44, 0x44, 0x44) rn2.italic = True ex_table2 = doc.add_table(rows=1, cols=5) ex_table2.style = 'Table Grid' hdr_cells2 = ex_table2.rows[0].cells for i, (hdr, w) in enumerate(zip(headers, widths)): cell = hdr_cells2[i] shade_cell(cell, '004E9A') p = cell.paragraphs[0] p.alignment = WD_ALIGN_PARAGRAPH.CENTER r = p.add_run(hdr) r.bold = True r.font.size = Pt(9) r.font.color.rgb = WHITE cell.width = w cell.vertical_alignment = WD_ALIGN_VERTICAL.CENTER exercises_wk26 = [ (1, 'Short Arc Quads', 'Towel under knee. Slowly straighten knee from 30° to full extension. Hold 5 sec. Lower slowly. DO NOT swing.', '10 reps', '3× day'), (2, 'Mini Squats\n(Wall Support)', 'Stand with back lightly against wall. Feet shoulder-width apart. Slowly bend both knees to 30°. Hold 5 sec. Straighten up.', '10 reps', '3× day'), (3, 'Sit to Stand', 'Sit on a firm chair. Slide to front. Lean forward slightly. Push up using chair arms and your legs equally. Lower yourself back slowly.', '10 reps', '3× day'), (4, 'Heel Raises\n(Standing)', 'Hold something steady. Rise up on your toes. Hold 5 sec. Lower slowly. Start with both feet, progress to one foot.', '10 reps', '3× day'), (5, 'Step-Ups', 'Hold rail/wall. Step up onto a low step (10 cm) with operated leg first. Bring other leg up. Step down with operated leg last.', '10 reps', '2× day'), (6, 'Hip Abduction\n(Standing)', 'Hold for support. Lift operated leg out to the side, keeping toes pointing forward. Hold 3 sec. Lower.', '10 reps', '3× day'), (7, 'Hamstring Curls', 'Standing, hold support. Bend operated knee, bringing heel toward buttock. Hold 5 sec. Lower slowly.', '10 reps', '3× day'), (8, 'Single-Leg Balance', 'Hold support lightly. Balance on operated leg for 10-30 sec. Progress to no support as confidence grows.', '5 holds', '3× day'), ] for ex in exercises_wk26: add_exercise_row(ex_table2, *ex) para_space(doc, before=6, after=0) # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 3 — WEEKS 6+ # ═══════════════════════════════════════════════════════════════════════════════ add_section_heading(doc, '📅 Week 6 and Beyond: Strengthening & Functional Exercises') p_note3 = doc.add_paragraph() p_note3.paragraph_format.space_before = Pt(2) p_note3.paragraph_format.space_after = Pt(4) rn3 = p_note3.add_run('Add these exercises when your physiotherapist advises. Continue all previous exercises.') rn3.font.size = Pt(9) rn3.font.color.rgb = RGBColor(0x44, 0x44, 0x44) rn3.italic = True ex_table3 = doc.add_table(rows=1, cols=5) ex_table3.style = 'Table Grid' hdr_cells3 = ex_table3.rows[0].cells for i, (hdr, w) in enumerate(zip(headers, widths)): cell = hdr_cells3[i] shade_cell(cell, '004E9A') p = cell.paragraphs[0] p.alignment = WD_ALIGN_PARAGRAPH.CENTER r = p.add_run(hdr) r.bold = True r.font.size = Pt(9) r.font.color.rgb = WHITE cell.width = w cell.vertical_alignment = WD_ALIGN_VERTICAL.CENTER exercises_wk6plus = [ (1, 'Stationary Cycling', 'Start with seat high (minimal bend). Cycle forward 10 min. Gradually lower seat to increase knee bend over weeks.', '10-20 min', '1× day'), (2, 'Step-Downs\n(Eccentric)', 'Stand on step. Slowly lower operated leg toward floor, bending standing knee to 30°. Touch floor lightly. Return up.', '10 reps', '2× day'), (3, 'Partial Squats\n(0–60°)', 'Feet shoulder-width. Squat to 60° only. Keep knees over toes. Hold 5 sec. Rise slowly.', '10 reps', '2-3× day'), (4, 'Lateral Band Walks', 'Light resistance band around ankles. Sidestep 10 steps right, 10 steps left. Keep knees slightly bent.', '3 sets', '2× day'), (5, 'Swimming / Aqua Walking', 'Once wound fully healed (6-8 wks). Walk in chest-deep water. Warm pool preferred. Excellent for pain-free strengthening.', '20-30 min', '3× week'), (6, 'Walking Programme', 'Increase distance daily. Start on flat. Progress to gentle inclines. Stop before pain develops. Rest, ice, elevate after.', 'As able', 'Daily'), ] for ex in exercises_wk6plus: add_exercise_row(ex_table3, *ex) para_space(doc, before=6, after=0) # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 4 — ROM GOALS # ═══════════════════════════════════════════════════════════════════════════════ add_section_heading(doc, '🎯 Range of Movement Targets') rom_table = doc.add_table(rows=5, cols=4) rom_table.style = 'Table Grid' rom_data = [ ('Timeframe', 'Bend (Flexion)', 'Straighten (Extension)', 'Milestone'), ('Week 1-2', '80-90°', '0° (full)', 'Walk with frame/crutches'), ('Week 2-6', '100-110°', '0° (full)', 'Walk independently at home'), ('3 Months', '120°+', '0° (full)', 'Stairs, driving, light work'), ('6-12 Months','120-135°', '0° (full)', 'Full daily activities'), ] rom_colors = ['004E9A', 'FFFFFF', 'F4F6F8', 'FFFFFF', 'F4F6F8'] rom_font_colors = [WHITE, None, None, None, None] for r_idx, (row_data, bg, fc) in enumerate(zip(rom_data, rom_colors, rom_font_colors)): row = rom_table.rows[r_idx] for c_idx, text in enumerate(row_data): cell = row.cells[c_idx] shade_cell(cell, bg) p = cell.paragraphs[0] p.paragraph_format.space_before = Pt(3) p.paragraph_format.space_after = Pt(3) p.alignment = WD_ALIGN_PARAGRAPH.CENTER run = p.add_run(text) run.font.size = Pt(9) run.font.name = 'Arial' if r_idx == 0: run.bold = True run.font.color.rgb = WHITE elif c_idx == 2 and r_idx > 0: run.bold = True run.font.color.rgb = GREEN para_space(doc, before=6, after=0) # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 5 — SWELLING & PAIN MANAGEMENT # ═══════════════════════════════════════════════════════════════════════════════ add_section_heading(doc, '🧊 Managing Pain and Swelling at Home') tips_table = doc.add_table(rows=1, cols=2) tips_table.alignment = WD_TABLE_ALIGNMENT.CENTER shade_cell(tips_table.cell(0,0), 'E8F5E9') shade_cell(tips_table.cell(0,1), 'FFF3E0') # Left: ICE lp = tips_table.cell(0,0).paragraphs[0] lp.paragraph_format.space_before = Pt(5) lp.paragraph_format.space_after = Pt(5) lr1 = lp.add_run('🧊 ICE THERAPY\n') lr1.bold = True lr1.font.size = Pt(10) lr1.font.color.rgb = BLUE_MID lr2 = lp.add_run( '• Wrap ice or frozen peas in a damp towel\n' '• Apply to knee for 15-20 minutes\n' '• Repeat 3-4 times per day\n' '• Always use a towel – never ice direct on skin\n' '• Ice AFTER exercises for best effect' ) lr2.font.size = Pt(9) # Right: ELEVATION rp = tips_table.cell(0,1).paragraphs[0] rp.paragraph_format.space_before = Pt(5) rp.paragraph_format.space_after = Pt(5) rr1 = rp.add_run('⬆️ ELEVATION\n') rr1.bold = True rr1.font.size = Pt(10) rr1.font.color.rgb = ORANGE rr2 = rp.add_run( '• Rest with leg raised above heart level\n' '• Place pillow under HEEL — not under knee\n' '• Keep knee as straight as possible when resting\n' '• Elevate for 20-30 min after exercise\n' '• Avoid prolonged sitting with knee bent' ) rr2.font.size = Pt(9) para_space(doc, before=6, after=0) # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 6 — DO / DON'T # ═══════════════════════════════════════════════════════════════════════════════ add_section_heading(doc, '✅ Do\'s and ❌ Don\'ts') dd_table = doc.add_table(rows=7, cols=2) dd_table.style = 'Table Grid' do_data = [ ('✅ DO', '❌ DO NOT'), ('Do your exercises every single day', 'Place a pillow under your knee when resting'), ('Keep the leg elevated when not walking', 'Kneel on the operated knee without a pad'), ('Ice the knee after exercises and when swollen', 'Force the knee into painful positions'), ('Walk little and often, increasing daily', 'Cross your legs'), ('Take pain relief as prescribed before exercises', 'Sit in low chairs or soft sofas in early weeks'), ('Keep surgeon/physio appointments', 'Drive until your surgeon gives the all-clear'), ] dd_colors_left = ['004E9A', 'E8F5E9', 'FFFFFF', 'E8F5E9', 'FFFFFF', 'E8F5E9', 'FFFFFF'] dd_colors_right = ['004E9A', 'FFEBEE', 'FFFFFF', 'FFEBEE', 'FFFFFF', 'FFEBEE', 'FFFFFF'] for r_idx, (left, right) in enumerate(dd_data): row = dd_table.rows[r_idx] shade_cell(row.cells[0], dd_colors_left[r_idx]) shade_cell(row.cells[1], dd_colors_right[r_idx]) for c_idx, (cell, text) in enumerate([(row.cells[0], left), (row.cells[1], right)]): p = cell.paragraphs[0] p.paragraph_format.space_before = Pt(4) p.paragraph_format.space_after = Pt(4) run = p.add_run(text) run.font.size = Pt(9) run.font.name = 'Arial' if r_idx == 0: run.bold = True run.font.color.rgb = WHITE elif c_idx == 0: run.font.color.rgb = GREEN else: run.font.color.rgb = ORANGE para_space(doc, before=6, after=0) # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 7 — RED FLAGS # ═══════════════════════════════════════════════════════════════════════════════ red_tbl = doc.add_table(rows=1, cols=1) shade_cell(red_tbl.cell(0,0), 'FFEBEE') set_cell_border(red_tbl.cell(0,0), val='single', sz='8', color='C62828') rp2 = red_tbl.cell(0,0).paragraphs[0] rp2.paragraph_format.space_before = Pt(6) rp2.paragraph_format.space_after = Pt(6) rr_1 = rp2.add_run('🚨 SEEK URGENT MEDICAL ATTENTION IF YOU NOTICE:\n') rr_1.bold = True rr_1.font.size = Pt(10) rr_1.font.color.rgb = RGBColor(0xC6, 0x28, 0x28) rr_2 = rp2.add_run( '• Sudden severe pain, redness, or warmth in the calf (possible DVT / blood clot)\n' '• Chest pain, shortness of breath, or coughing blood (possible PE)\n' '• Fever above 38°C, chills, or the wound feels hot and discharges pus (possible infection)\n' '• The knee gives way or you feel a "clunk" / sudden instability\n' '• Wound edges separate or drainage through the dressing does not stop' ) rr_2.font.size = Pt(9.5) rr_2.font.name = 'Arial' para_space(doc, before=6, after=0) # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 8 — STAIR TECHNIQUE & WALKING AIDS # ═══════════════════════════════════════════════════════════════════════════════ add_section_heading(doc, '🪜 Stairs, Walking Aids & Daily Tips') stair_tbl = doc.add_table(rows=1, cols=2) shade_cell(stair_tbl.cell(0,0), 'E3F2FD') shade_cell(stair_tbl.cell(0,1), 'F3E5F5') sp1 = stair_tbl.cell(0,0).paragraphs[0] sp1.paragraph_format.space_before = Pt(5) sp1.paragraph_format.space_after = Pt(5) sr1 = sp1.add_run('🪜 STAIRS\n') sr1.bold = True sr1.font.size = Pt(10) sr1.font.color.rgb = BLUE_MID sr2 = sp1.add_run( 'GOING UP:\n' '"Good leg goes UP first"\n' '(Good leg → Operated leg → Crutch)\n\n' 'GOING DOWN:\n' '"Bad leg goes DOWN first"\n' '(Crutch → Operated leg → Good leg)\n\n' 'Always use the handrail!' ) sr2.font.size = Pt(9) sp2 = stair_tbl.cell(0,1).paragraphs[0] sp2.paragraph_format.space_before = Pt(5) sp2.paragraph_format.space_after = Pt(5) sr3 = sp2.add_run('🚶 WALKING AIDS\n') sr3.bold = True sr3.font.size = Pt(10) sr3.font.color.rgb = BLUE_MID sr4 = sp2.add_run( 'Frame → 2 Crutches → 1 Stick → None\n\n' '• Wean aids as pain and confidence improve\n' '• Use 1 stick on the OPPOSITE side\n' ' to your operated knee\n' '• Continue using aid outdoors until\n' ' you walk without a limp\n' '• Do NOT rush — use aids as long as needed' ) sr4.font.size = Pt(9) para_space(doc, before=6, after=0) # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 9 — RETURN TO ACTIVITIES TIMELINE # ═══════════════════════════════════════════════════════════════════════════════ add_section_heading(doc, '📆 Return to Activities Timeline') act_table = doc.add_table(rows=9, cols=2) act_table.style = 'Table Grid' act_data = [ ('Activity', 'Approximate Timeframe'), ('Walking indoors unaided', '2-4 weeks'), ('Light housework', '3-6 weeks'), ('Driving (right knee / automatic)', '6-8 weeks (surgeon approval)'), ('Driving (left knee / manual)', '10-12 weeks (surgeon approval)'), ('Office/sedentary work', '6-8 weeks'), ('Physical/standing work', '3-6 months'), ('Swimming (wound healed)', '6-8 weeks'), ('Cycling, golf, gentle hiking', '3-4 months'), ] for r_idx, (act, time) in enumerate(act_data): row = act_table.rows[r_idx] if r_idx == 0: shade_cell(row.cells[0], '004E9A') shade_cell(row.cells[1], '004E9A') fc_act = WHITE elif r_idx % 2 == 0: shade_cell(row.cells[0], 'F4F6F8') shade_cell(row.cells[1], 'F4F6F8') fc_act = None else: shade_cell(row.cells[0], 'FFFFFF') shade_cell(row.cells[1], 'FFFFFF') fc_act = None for cell, text in [(row.cells[0], act), (row.cells[1], time)]: p = cell.paragraphs[0] p.paragraph_format.space_before = Pt(3) p.paragraph_format.space_after = Pt(3) run = p.add_run(text) run.font.size = Pt(9) run.font.name = 'Arial' if r_idx == 0: run.bold = True run.font.color.rgb = WHITE elif fc_act: run.font.color.rgb = fc_act para_space(doc, before=6, after=0) # ═══════════════════════════════════════════════════════════════════════════════ # FOOTER # ═══════════════════════════════════════════════════════════════════════════════ footer_tbl = doc.add_table(rows=1, cols=1) shade_cell(footer_tbl.cell(0,0), '004E9A') fp = footer_tbl.cell(0,0).paragraphs[0] fp.alignment = WD_ALIGN_PARAGRAPH.CENTER fp.paragraph_format.space_before = Pt(6) fp.paragraph_format.space_after = Pt(6) fp.add_run('Physiotherapist: ___________________________ ') fp.add_run('Contact: ___________________________ ') fp.add_run('Next Appointment: ___________________') for run in fp.runs: run.font.size = Pt(8.5) run.font.color.rgb = WHITE run.font.name = 'Arial' # ── Save ────────────────────────────────────────────────────────────────────── out_path = '/tmp/workspace/tkr-handout/Post_TKR_Home_Exercise_Handout.docx' doc.save(out_path) print(f"Saved: {out_path}") PYEOF echo "Script written."

Running Command

cd /tmp/workspace/tkr-handout && python3 create_handout.py

Running Command

python3 -c "from docx.shared import RGBColor; c = RGBColor(0x00, 0x7B, 0xC2); print(dir(c)); print(type(c))"

Editing File

~/tkr-handout/create_handout.py

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/tkr-handout/create_handout.py'

Running Command

cd /tmp/workspace/tkr-handout && python3 create_handout.py

Running Command

python3 -c " exercises_wk12 = [ (1, 'Ankle Pumps', 'Lying or sitting. Bend your foot up toward you, then point it down. Keep moving rhythmically.', '30 reps', 'Every hour'), (2, 'Quad Sets', 'Lying flat. Push the back of your knee DOWN into the bed. Pull toes toward you. Hold 10 sec.', '10 reps', '4x day'), ] for ex in exercises_wk12: print(len(ex), ex) "

Reading File

Editing File

~/tkr-handout/create_handout.py

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/tkr-handout/create_handout.py'

Running Command

cd /tmp/workspace/tkr-handout && python3 create_handout.py 2>&1

Running Command

cd /tmp/workspace/tkr-handout && sed -i 's/for r_idx, (left, right) in enumerate(dd_data):/for r_idx, (left, right) in enumerate(do_data):/' create_handout.py && python3 create_handout.py 2>&1

Running Command

ls -lh /tmp/workspace/tkr-handout/Post_TKR_Home_Exercise_Handout.docx

Your handout is ready:

Post TKR Home Exercise Handout

Word Document · DOCX

Here is what the handout contains (A4, print-ready):

1. Header Banner - "Home Exercise Programme After Total Knee Replacement" with patient name and date of surgery fields

2. Week 1-2 Exercise Table (8 exercises)

Ankle Pumps, Quad Sets, Straight Leg Raise, Inner Range Quads, Heel Slides, Static Glute Squeeze, Full Range Knee Extension, Knee Flexion in Sitting
Each with: how to do it, reps, times per day
Colour-coded rows (alternating white/grey), blue numbered column

3. Prominent Warning Box - "Never place pillow under knee - full extension is the most important early goal"

4. Weeks 2-6 Exercise Table (8 exercises)

Short Arc Quads, Mini Squats, Sit to Stand, Heel Raises, Step-Ups, Hip Abduction, Hamstring Curls, Single-Leg Balance

5. Week 6+ Strengthening Table (6 exercises)

Cycling, Step-Downs, Partial Squats, Lateral Band Walks, Swimming, Walking Programme

6. ROM Targets Table - Flexion/extension goals at each timeframe with milestones

7. Pain & Swelling Management - Ice therapy + elevation side-by-side boxes

8. Do's and Don'ts Table - Green Do's vs Orange Don'ts

9. Red Flag Box - DVT, PE, infection, instability warning signs

10. Stairs & Walking Aids - "Good leg up, bad leg down" rule + aid progression

11. Return to Activities Timeline - Driving, work, sports milestones

12. Footer - Physiotherapist name, contact, next appointment fields

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