Hey so I want you to prepare me a prescription as a physiotherapist of a case, a patient with bilateral knee pain suffering from rheumatoid arthritis from past 20 years and grade for osteoarthritis. The patient is 62 years old named Jessica female. The numerical rating came for pain is 10 out of 10. She feel pain by performing ideas. She has morning stiffness which long last till afternoon and gradually gets decreases as a day passes and increases as the early morning starts his physician or rheumatologist recommended taps and prolonged the treatment for 20 years and avoided the surgery because the longevity of the implant will be 20 years so he just wanted her to done her to be done her surgery, but you know late 60s or 70s now she’s going for a knee replacement for knee. She used to manage her pain by using tropical agents, hot pack and a physiotherapist who make her to do isometrics apply and IFT and laser for three weeks. She felt a bit improvement 10 to 15% in from pain so that the NRS will be 9 out of 10 for an hour or couple of hours again. Then she start feeling pain. So now she’s going for the surgery. Say me the exercises or the management for pre-operative care as a physiotherapist to her. She even have the history of diabetes, hypertension and thyroid. She even have the sleep disturbance due to pain. After finding in the x-ray itself. It is grade 4 hours to arthritis now. Write a precise prescription according to a well settled physiotherapist.
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preoperative physiotherapy prescription rheumatoid arthritis grade 4 osteoarthritis bilateral knee TKR prehabilitation 2024
I now have sufficient information to compile a thorough, clinically grounded pre-operative physiotherapy prescription. Let me write this up.
PHYSIOTHERAPY PRE-OPERATIVE PRESCRIPTION
Clinic/Department: Musculoskeletal & Orthopaedic Physiotherapy Unit
Date: 21 July 2026
Physiotherapist: [Your Name & Registration No.]
PATIENT PROFILE
| Detail | Information |
|---|---|
| Name | Jessica |
| Age | 62 years |
| Sex | Female |
| Diagnosis | Bilateral Knee Pain - Rheumatoid Arthritis (20 years) + Grade IV Osteoarthritis (X-ray confirmed) |
| Planned Surgery | Bilateral Total Knee Replacement (TKR) |
| NRS Pain Score | 10/10 (baseline); 9/10 post-previous PT for 1-2 hours only |
| Comorbidities | Type 2 Diabetes Mellitus, Hypertension, Hypothyroidism |
| Symptom Pattern | Morning stiffness persisting till afternoon, worsens at night/early morning, pain on all ADLs |
| Sleep | Disturbed due to pain |
| Previous PT | Isometrics, IFT, Laser, Hot packs, Topical agents - 3 weeks; minimal improvement |
| Prior Management | DMARDs/DMARD-based therapy for 20 years under Rheumatologist; surgery deferred due to implant longevity concerns |
PHASE: PRE-OPERATIVE PREHABILITATION (Prehab)
Duration: 2-4 weeks pre-surgery (or as long as available before surgery date)
Goal: Optimize surgical outcomes, reduce post-op complications, build muscle reserve, and educate Jessica before TKR.
PHYSIOTHERAPY ASSESSMENT SUMMARY
| Parameter | Finding |
|---|---|
| Pain (NRS) | 10/10 at rest and with activity |
| Morning Stiffness | Prolonged (till afternoon) |
| ROM Bilateral Knees | Likely severely restricted - confirm with goniometry (expected: flexion < 90°, extension lag present) |
| Muscle Strength (MMT) | Quadriceps likely Grade 2-3/5 bilaterally |
| Functional Status | Severely limited ADLs, unable to perform basic mobility tasks without pain |
| Gait | Antalgic gait expected; assess with assistive device need |
| Edema/Effusion | Likely present bilaterally - document via circumferential measurement |
| Psychological | Sleep-deprived, chronic pain - high risk of anxiety/fear-avoidance |
GOALS OF PRE-OPERATIVE PHYSIOTHERAPY
- Reduce pain and joint inflammation to a manageable level
- Strengthen periarticular muscles (especially quadriceps, hamstrings, glutes, hip abductors)
- Maintain/improve available ROM in both knees
- Improve cardiovascular endurance within pain-free limits
- Educate Jessica on post-operative exercises and expectations
- Address sleep hygiene and pain neuroscience
- Reduce psychological fear and improve surgical confidence
TREATMENT PLAN
A. PAIN MANAGEMENT MODALITIES
1. Interferential Therapy (IFT)
- Frequency: 4 kHz carrier, beat frequency 80-100 Hz for pain relief (chronic pain mode)
- Duration: 15-20 minutes per knee
- Application: Quadripolar placement around both knees
- Frequency of sessions: 5 days/week
2. Transcutaneous Electrical Nerve Stimulation (TENS)
- Mode: Conventional TENS (high frequency 80-100 Hz, low intensity)
- Duration: 20-30 minutes per knee
- Purpose: Endorphin-mediated pain gate mechanism; can be used at home between sessions
- Note: Instruct Jessica on home TENS unit use for overnight pain and morning stiffness management
3. Low-Level Laser Therapy (LLLT)
- Dosage: 4-8 J/cm² per point
- Points: Medial joint line, lateral joint line, suprapatellar pouch, popliteal fossa
- Duration: 10-15 minutes per knee
- Evidence: Demonstrated short-term pain relief in OA and RA
4. Hot Pack (Moist Heat)
- Apply 15-20 minutes before exercise to reduce morning stiffness and improve tissue extensibility
- Caution: Monitor skin carefully given diabetic neuropathy risk - use thermometer or elbow test; avoid if peripheral neuropathy confirmed
Note on morning stiffness: On days of prolonged morning stiffness, delay exercise session to afternoon when stiffness naturally reduces. Schedule physiotherapy for 2-4 PM if possible.
B. THERAPEUTIC EXERCISE PROGRAM
All exercises prescribed at pain-free or tolerable range only (NRS ≤ 4/10 during exercise).
Precautions:
- No high-impact loading
- No deep knee bending beyond available range
- Monitor blood pressure pre/post exercise (Hypertension)
- Monitor blood glucose pre/post exercise (DM) - ensure she is not fasting
- Thyroid-related fatigue - limit session duration to 30-40 minutes; rest between sets
WEEK 1-2: Foundation/Low-Intensity Phase
| # | Exercise | Sets x Reps | Notes |
|---|---|---|---|
| 1 | Ankle Pumps (bilateral) | 3 x 20 | Circulatory warm-up, DVT prevention |
| 2 | Supine Quad Sets (Isometric Quads) | 3 x 10 x 10 sec hold | Flatten knee to bed, tighten quad; pain-free |
| 3 | Isometric Hamstring Contraction | 3 x 10 x 10 sec hold | Heel press into bed; supine |
| 4 | Isometric Gluteal Squeeze | 3 x 10 x 10 sec hold | Both sides; supine |
| 5 | Supine Hip Abduction (sliding) | 2 x 10 each side | Slide on smooth surface; strengthens hip abductors |
| 6 | Heel Slides (Active Assisted Knee Flexion) | 2 x 10 each side | Gentle ROM; supine, slide heel toward buttocks as tolerated |
| 7 | Short Arc Quads (SAQ) | 3 x 10 each side | Support under knee at 30° flexion, extend to 0°; builds terminal quad strength |
| 8 | Straight Leg Raise (SLR) | 3 x 10 each side | Core stability + quad; only if no extension lag |
| 9 | Seated Knee Extension (gravity-eliminated) | 2 x 10 each side | Seated on edge of bed; low resistance |
| 10 | Deep Breathing Exercises | 5 mins | Diaphragmatic; manages hypertension, reduces anxiety |
WEEK 3-4: Progressive Phase
| # | Exercise | Sets x Reps | Notes |
|---|---|---|---|
| 1 | Standing Hip Abduction (supported) | 3 x 10 each side | Hold chair/rail; strengthens hip abductors for post-op gait |
| 2 | Standing Hip Extension (supported) | 3 x 10 each side | Glute strengthening |
| 3 | Mini Squats / Partial Squats (0°-30°) | 2 x 10 | Only to pain-free range; chair behind for safety |
| 4 | Terminal Knee Extension with Theraband | 3 x 10 each | Theraband at popliteal fossa; 30°-0° arc only |
| 5 | Seated Calf Raises | 3 x 15 | Circulatory + DVT prevention |
| 6 | Step-ups (low step, 2-3 inches) | 2 x 5 each side | Only if tolerated; builds functional lower limb strength |
| 7 | Cycling (stationary, low resistance) | 10-15 mins | Excellent low-impact ROM + cardiovascular; adjust seat high to limit flexion beyond comfort |
| 8 | Pool Therapy / Hydrotherapy (if available) | 20-30 mins | Buoyancy reduces joint load; warmth eases stiffness; ideal for RA + OA |
| 9 | Core Activation: Abdominal Bracing | 3 x 10 x 10 sec | Supine; improves functional stability |
C. MANUAL THERAPY (Gentle Grade I-II Mobilizations)
- Patellofemoral Glides: Medial/lateral patellar glides to maintain patellar mobility
- Tibio-femoral Distraction: Grade I-II traction to reduce joint compression pain
- Soft Tissue Massage: Quadriceps, hamstrings, calf (gastrocnemius/soleus) - reduce hypertonicity and improve extensibility
- Scar Tissue / Fascial Release: Not applicable pre-op, but educate regarding post-op scar mobility
Caution: Given RA with active inflammatory phase (morning stiffness till afternoon), avoid aggressive mobilization during flare periods. Treat gently in pain-free range only.
D. ASSISTIVE DEVICE TRAINING
- Assess and prescribe appropriate walking aids: bilateral elbow crutches or a wheeled walker (rollator)
- Train Jessica in safe stair climbing, sitting-to-standing transfers, car transfers before surgery so she knows exactly what to do post-operatively
- Train use of long-handled aids (sock aid, grabber) to promote joint protection and independence
E. ELECTROTHERAPY SUMMARY TABLE
| Modality | Parameters | Duration | Frequency |
|---|---|---|---|
| IFT | 4 kHz carrier, 80-100 Hz beat, quadripolar | 15-20 min/knee | 5x/week |
| TENS (home) | Conventional, 80-100 Hz | 20-30 min/session | As needed (esp. nights) |
| LLLT | 4-8 J/cm², 810-904 nm | 10-15 min/knee | 3x/week |
| Moist Hot Pack | 40-42°C | 15-20 min | Pre-exercise daily |
F. EDUCATION & PATIENT COUNSELLING
This is a mandatory component of prehabilitation, supported by recent evidence showing pre-operative education significantly reduces post-op anxiety and improves functional outcomes.
- Pain neuroscience education: Explain central sensitization, why her pain is 10/10 even at rest, and what to expect from surgery
- Post-operative exercise preview: Teach her the exact exercises she will do from Day 1 post-TKR (ankle pumps, quad sets, SLR, heel slides) so they feel familiar, not frightening
- Breathing and relaxation techniques: For sleep improvement and pre-op anxiety
- Joint protection principles: Protect knees during ADLs; avoid kneeling, squatting, low chairs
- Sleep hygiene: Pillow positioning (small pillow under calf, NOT under knee - knee contracture risk), TENS use at night, relaxation before bed
- Diabetes management during rehab: Coordinate with physician - blood glucose should be 140-180 mg/dL range; exercise cautiously if >300 or <80 mg/dL
- Wound and DVT awareness post-op: Warning signs, importance of early mobility
- Nutritional advice (refer to dietician): Protein intake for muscle building (1.2-1.5 g/kg/day), Vitamin D, Calcium for bone health - especially important in RA + post-menopausal female
G. SPECIAL CONSIDERATIONS
| Comorbidity | Physiotherapy Consideration |
|---|---|
| Rheumatoid Arthritis (active) | Avoid therapy during flare; monitor joint inflammation; avoid aggressive loading; coordinate with Rheumatologist regarding DMARD status pre-op (MTX, biologics often held 1-2 weeks pre-surgery) |
| Diabetes Mellitus | Check blood glucose before/after exercise; monitor feet for neuropathy; hot pack precautions; wound healing risk |
| Hypertension | Monitor BP pre/post exercise; Borg RPE < 13 (moderate); no Valsalva maneuver; avoid isometric holds >10 seconds in later phases |
| Thyroid (Hypothyroid) | Fatigue may be prominent; shorter sessions with rest periods; monitor heart rate response |
| Sleep Disturbance | Address directly - TENS at night, positioning education, relaxation breathing, refer to sleep counsellor if needed |
| Bilateral involvement | Both legs are affected - prescribe bilateral exercises equally; note that bilateral TKR recovery is more demanding than unilateral |
H. FUNCTIONAL OUTCOME TARGETS (Pre-op)
| Goal | Target Before Surgery |
|---|---|
| Pain (NRS) | Reduce from 10/10 to 6-7/10 at rest |
| Knee Flexion ROM | Achieve at least 90° bilaterally |
| Knee Extension ROM | Full extension or < 5° extension lag |
| Quadriceps Strength | Improve from Grade 2-3 to Grade 3-4/5 |
| Walk 50 meters | With assistive device, without stopping |
| ADL independence | Transfers, toilet, basic indoor mobility |
| Anxiety | Patient confident and informed about surgery |
I. SESSION SCHEDULE
| Day | Morning | Afternoon |
|---|---|---|
| Monday | Physiotherapy clinic - full session (IFT + Exercise) | Home TENS if needed |
| Tuesday | Home exercise program | Rest / gentle walking |
| Wednesday | Physiotherapy clinic - full session (Laser + Manual + Exercise) | Home TENS |
| Thursday | Home exercise program | Rest |
| Friday | Physiotherapy clinic - full session (IFT + Hydrotherapy if available) | Home TENS |
| Saturday | Light home exercises + walking | Rest |
| Sunday | Rest | Relaxation + breathing exercises |
J. REFERRALS & COORDINATION
- Rheumatologist: Confirm DMARD/biologic holding protocol pre-op (standard: Methotrexate held 1 week, biologics held 1-2 half-lives before surgery)
- Orthopaedic Surgeon: Share prehab progress report 1 week before surgery
- Diabetologist/Physician: Optimize HbA1c < 8% before surgery (wound healing risk above this)
- Dietician: Nutritional optimization
- Psychologist/Counsellor: If sleep disturbance and chronic pain fear-avoidance persist
PRE-OP PREHAB OUTCOME NOTE
Jessica presents with a highly complex multimorbid profile - 20-year RA plus end-stage Grade IV bilateral OA, NRS 10/10, diabetic, hypertensive, and hypothyroid. The goals of pre-operative physiotherapy are not to cure her pain - that is the surgery's job - but to ensure she enters the operating theatre as physically and psychologically prepared as possible.
Evidence from the 2022 systematic review by Vasileiadis et al. confirms that pre-operative physiotherapy improves post-TKR functional recovery. Resistance training before TKR has been shown to improve post-operative functional performance per Jorgensen et al., 2022. A rapid review by Anderson et al., 2022 further outlines the content and delivery framework for pre-operative TKR interventions.
Physiotherapist Signature: ___________________________
Date: 21 July 2026
Review Date: 1 week pre-surgery
Next Appointment: ___________________________
Important disclaimer: This prescription is a clinical framework based on standard physiotherapy evidence for pre-operative TKR management. Actual treatment must be adjusted session-by-session based on Jessica's real-time presentation, pain response, and comorbidity status. All electrotherapy parameters, exercise progressions, and session frequencies should be modified by the treating physiotherapist during hands-on assessment.
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