Effect of Pre-operative Patient Education Program on Functional Outcomes After Total Knee Arthroplasty
Phase: NA
Conditions: Knee Arthropathy
Sponsor: University of the State of Santa Catarina

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SANTA CATARINA STATE UNIVERSITY - UDESC  
CENTER FOR HEALTH AND SPORTS SCIENCES – CEFID 
GRADUATE  PROGRAM IN PHYSICAL THERAPY 
 
 
 
 
BIBIANA MELHER PEREIRA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EFFECT OF PREOPERATIVE PATIENT EDUCATION 
PROGRAM ON FUNCTIONAL OUTCOMES AFTER 
TOTAL KNEE ARTHROPLASTY 
 
 
 
 
 
 
 
 
 
 
STUDY PROTOCOL 
 
 
 
 
 
 
 
FLORIANÓPOLIS 
2017 

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ABSTRACT 
 
 
The knee is one of the joints most affected by osteoarthritis (OA), causing individuals to present 
joint stiffness, muscle weakness and proprioceptive deficit limiting the performance of daily 
activities. Total knee arthroplasty (TKA) presents good results in reducing the pain and stiffness 
of individuals in the final phase of OA. However, changes in gait and strength may persist 
postoperatively. Preoperative guidance for TKA were efficient in reducing pain and functional 
deficits and improving quality of life, however the functionality was measured by scales. Thus, 
this study aims to evaluate the effect of preoperative guidance on three-dimensional gait 
analysis, functional mobility, postural control and kinesiophobia level in subjects with TKA. 
Will be recruited patients of both sexes undergo unilaterally TKA in the city of Florianópolis 
and referred by an orthopedist to the Physiotherapy Clinic of UDESC. These will be divided 
into two groups: one that will receive verbal guidance and a leaflet with information related to 
their physical condition as well as signs and symptoms in the postoperative period and a group 
that will receive only verbal guidance. Both groups will be evaluated by a blind evaluator in the 
preoperative and postoperative periods (6 weeks and 6 months). The evaluations will be divided 
into five stages. Anthropometric measurements of the individual will be made and then the 
WOMAC functionality questionnaire and the Tampa Scale of Kinesiophobia will be applied. 
Then the individual will walk by 5 meters for three-dimensional gait analysis through the Vicon 
System, AMTI Force Platforms and Noraxon electromyograph. A functional mobility 
assessment will also be performed by Timed Up And Go. Finally, evaluation of the postural 
control with Neurocom Equilibrium Platform will be performed. Statistical data will be 
analyzed by analysis of variance 3x2 considering time factor (pre, post 6 weeks and post 6 
months) and groups (with and without information leaflet). The p-value used will be 0.05. 
 
Palavras-chave: osteoarthrosis, total knee arthroplasty, physiotherapy, gait analysis, guidance 
 
 
 
 
 
 

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1 INTRODUCTION 
 
1.1 CONTEXTUALIZATION OF THE PROBLEM  
The current extension of life expectancy leads to an increase in the elderly population, 
commonly affected by degenerative diseases such as osteoarthrosis (OA) (MILNER, 2009; 
YAARI et al, 2015). OA is the chronic-degenerative disease that most affects the elderly. In 
Brazil there is a lack of consistent data, but a prevalence of 26.5% is inferred. The knee is 
especially affected, between 23% and 40% of the elderly population, being more prevalent in 
women and over 74 years (SALVATO et al, 2015). Its onset and progression may be related to 
age, changes in metabolism, genetic and hormonal factors, biomechanical changes and 
inflammatory joint processes. The symptomatology goes from pain and joint stiffness to 
deformities and progressive loss of function (SANTOS et al, 2011). Thus, the treatment of this 
population should seek to reestablish independence and quality of life, where the resource 
commonly used in the final stages of OA is total knee arthroplasty (TKA) (HIYAMA et al, 
2015).  
The articular surface replacements began in the 1940s, undergoing continuous advances 
(VASCONCELOS et al, 2013), and are today the most effective surgery interventions in 
terminal phases of OA for success in reducing pain and joint stiffness (CASARTELLI et al, 
2013). However, changes in strength, joint mobility, and gait may remain or worsen after joint 
(HIYAMA et al, 2015).  
The recovery of gait function is one of the main objectives after TKA (CASARTELLI 
et al, 2013), because this activity is related to the independence of the individual besides being 
one of the activities that presents a higher incidence of fall in the elderly (HALLAL et al, 2013). 
Abnormal gait patterns may predispose to new degenerative processes or early deterioration of 
the prosthesis. Thus, identifying abnormalities makes it possible to trace treatment strategies 
for its correction (MILNER, 2009).  
The use of scales and questionnaires is highly used in the evaluation of pain and post-
TKA functionality. However, the subjectivity of these evaluations interferes in the 
quantification of the functional framework and, therefore, in the therapeutic direction. Evidence 
suggests that measures based on performance are more likely to characterize changes in 
function than self-reports (YUKSEL et al, 2016).  
Investigations of the kinematics in the TKA showed lower flexion in the initial contact 
phase and less flexion in the oscillation phase. These individuals also had greater varus in 

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response to the load when compared in asymptomatic individuals (VASCONCELOS et al, 
2013). Research associating three-dimensional gait assessment with electromyography (EMG) 
found patterns that differed from normal, but no preoperative data were collected from 
individuals in order to quantify the changes that occurred (VILLARDI et al, 2005; LEE et al, 
2015). 
He knows that the variability of step time depends on the sum of factors physical function, 
ability to balance and mental state, such as the confidence of the individual in his ability to 
perform the activity (HYIAMA et al, 2015). There is evidence that persistence of pain can not 
be based solely on clinical findings, making a purely clinical intervention inefficient 
(SIQUEIRA et al, 2007). Pain education can alter beliefs about pain, such as the fact that it is 
related to tissue damage and disability (LOUW et al, 2013), Showing reduction of pain, 
functional deficits and improvement of the quality of life in patients who received guidance for 
the postoperative period (MONTICONE et al, 2013). 
A review study has shown that preoperative guidance themselves can not modify the 
patient's physical condition but improve the ability to cope with pain and feel prepared for 
surgery by reducing anxiety and increasing postoperative comfort  (AYDIN et al, 2015). Fear 
of movement pain characterizes kinesiophobia, where the individual ceases to perform 
activities inducing a vicious cycle, which results in decreased joint mobility, muscular strength 
and proprioception, thus increasing the pain experience (MONTICONE et al, 2013). 
Although there were studies on the effect of preoperative guidance on patients with 
TKA, mobility was assessed only through functional questionnaires, with no objective 
information on the behavior of the spatial-temporal and kinetic parameters of gait, postural 
control and functionality. Thus, this study aims to evaluate the effect of preoperative guidances 
on functional gait recovery and kinesiophobia level in subjects post TKA. 
 
 
1.2 OBJECTIVE 
 
The study was designed to evaluate the effect of preoperative patient education 
program on functional outcomes after total knee arthroplasty. 
 
1.3 HYPOTHESES OF RESEARCH 

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 H0: There is no difference on functional outcomes on functional otucomes after  
TKA in patients  that received preoperative information and those who did not. 
 H1: There is difference on functional outcomes on functional otucomes after  
TKA in patients  that received preoperative information and those who did not 
 
 
3 METHODOLOGY 
 
3.1 STUDY DESIGN 
 
This study is a single-center, prospective, parallel-group, randomized clinical trial 
(HULLEY et al, 2015). 
 
3.2 PARTICIPANTS 
 
Sample size estimation calculations were performed taking into consideration the primary 
outcome measure - Timed up and Go (TUG) test score. These calculations were based on the 
study published by Mizner et al (2005), and considering a Minimal Clinically Important Change 
of 2,27 seconds in the TUG score (Yuksel et al, 2016). Considering a power of 80% and a two-
sided 0.05 significance level, 28 patients would be necessary to detect a 2.27 second difference 
between the two arms (14 patients in each arm). Considering a dropout rate of 10%, the total 
sample size would be 31 patients. We have decided to extend the sample size to 40 patients (20 
patients in each arm), assuming small variations on the baseline TUG scores and standard 
deviation in the study population..  
The sample will be recruited between patients of both sexes with indication for total 
unilateral knee arthroplasty in the city of Florianópolis and referred by orthopedic physicians. 
The collection will take place in the period between July 2017 and April 2018. Participants will 
be divided into two groups of equal size: intervention group (GI) who will receive preoperative 
oral guidance and a leaflet with information related to their physical condition as well as signs 
and symptoms in the postoperative period (APPENDIX A); Control group (GC) who will 
receive only verbal guidance in the preoperative period. 
The evaluations will occur in three moments (preoperative, 6 weeks and 6 months after 
the arthroplasty). On the day of the first collection, the participants will be allocated to each 

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group according to the draw made by a team member who will not participate in the evaluations. 
This same member will deliver the package leaflet to the GI participants. Evaluators will be 
blinded to individuals participating in IG and GC. All participants will receive information 
about the objectives and procedures of the study through the Informed Consent Form 
(APPENDIX B) prior to the collection. 
 
3.2.1 Inclusion and exclusion criteria 
 
 
The following criteria will be used: 
Inclusion: 
- Age above 55 years; 
- Literate; 
- Elective submission of total unilateral knee arthroplasty (TKA) due to osteoarthrosis;- 
Que não tenham realizado substituição unicompartimental anterior ou osteotomia de tíbia no 
mesmo joelho; 
- Who have not had knee infection or other serious complications after TKA; 
- Body mass index less than 40 kg / m2; 
- That he has not performed other arthroplasties on the lower limb in the last 6 months; 
- Movement arc greater than 90º in the operated or contralateral knee. 
 
Exclusion 
- Associated condition that impedes performance in gait tests, including significant 
osteoarthrosis in the contralateral knee or hips (defined as pain greater than or equal to 5 in 
VAS); 
- Absence or abandonment in the study follow-up sessions. 
 
Blinding 
The nature of the study will allow blinding of the patients regarding study arms. 
Participants will be blinded to the primary and secondary outcomes being measured. Baseline 
patient assessment, as well as outcomes assessment at 6 weeks and 6 months will be performed 
by one investigator blinded for experimental or active comparator arms. Statistical analysis will 
be performed blinded for experimental or active comparator arms. 
 

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Patient assessment 
Patients will be assessed at baseline (pre-operatively), in 6 weeks after surgery and 6 
months fter surgery. 
 
Baseline assessment 
Participant characterization will consist of: 
a) Demographics (gender, date of birth); 
b) Educational level (years); 
c) Diagnosis 
d) Affected side 
e) Date of surgery 
f) Gait analysis 
g) Timed Up and Go test 
h) Knee Osteoarthritis Score - WOMAC 
i) EMG muscle activity 
j) Kinesiophobia 
l) Postural control 
 
3.3 OPERATIONAL AND CONCEPTUAL DESCRIPTION OF THE VARIABLES 
 
3.3.1 Simple support and double support time  
 
Simple support is characterized by contact with the ground with only one foot. When 
the two feet are in contact with the ground, the double support is characterized. (VILLARDI et 
al, 2005). Variables will be expressed in seconds. 
 
3.3.2 Stride and step length 
 
Step is the range of gait between the initial contact of one foot and the initial contact of 
the other foot. Past is based on the actions of a member, it lasts the interval between two 

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sequential contacts of the same member in the ground (PERRY, 2005). Both will be expressed 
in centimeters. 
 
3.3.3 Adductor moment in gait 
 
The external adductor moment is the biomechanical measurement for medial load of the 
knee, the larger the external adductor moment the greater the load in the medial compartment 
of the knee. Thus, this shows a large incidence in OA, being a better predictor of OA 
progression. The frontal evaluation of the knee can elucidate the effect of the prosthesis on the 
response of the medial load in the knee and eventual compensations in the contralateral knee 
that can contribute to the progression of OA. (ALNAHDI et al, 2011). The variable will be 
expressed in N/m. 
 
3.3.4 Knee flexion angle in gait 
 
The knee flexion joint angle is measured between the longitudinal axis of the thigh and 
the longitudinal axis of the leg, knowing that in the anatomical reference position all articular 
angles are equal to zero (HALL, 2013). The knee flexion in the load response will be measured 
using the Vicon MX system. The variable will be expressed in degrees. 
 
3.3.5 Electromyographic activity 
 
The electromyographic signal is expressed in root mean square (RMS), obtained 
through the mean and median frequency of the signal and temporal analysis of the signal. The 
RMS indicates the chronological activation of the motor units and the amplitude of the muscular 
activation before the applied exercise (GONÇALVES e SILVA, 2007). 
The variable will be expressed as a percentage by normalizing the maximum voluntary 
contraction. It will be evaluated by the Telemyo DTS electromyograph (NoraxonTM). 
 
3.3.6 Self-reported functionality by WOMAC (Western Ontario and McMaster Universities 
Osteoarthritis Index) 
 

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The WOMAC questionnaire has 24 items distributed in the dimensions pain, stiffness 
and function with scores from 0 to 100, being 0 = none, 25 = few, 50 = moderate, 75 = intense 
and 100 = very intense. The higher the final score, the greater the functional impairment of the 
individual (GIESINGER et al, 2015). In this study the validated version for the Portuguese 
language will be used (Fernandes et al, 2003). 
 
3.3.7 Kinesiophobia 
 
Excessive, irrational and debilitating fear of movement and physical activity that results 
in feelings of vulnerability to pain or fear of injury recurrence is classified as kinesiophobia and 
can be assessed by the Tampa Scale of Kinesiophobia (SIQUEIRA et al, 2007). This variable 
is dimensionless and will be evaluated by the TAMPA scale. 
 
3.3.8. Functional mobility by TUG (Timed Up And Go) 
 
The TUG assesses the functional capacity of individuals by means of temporal analysis 
to perform lifting, walking, turning and sitting (PODSIADLO e RICHARDS, 1991). It is a 
temporal variable that will be measured in seconds. 
 
3.3.9 Center of gravity oscillation speed 
 
Center of gravity is the point at which the torques produced by the weights of the body 
segments are equal to zero, this measure oscillates in the direction of the largest mass of a 
moving body (HALL, 2013). This variable is measured in seconds and will be evaluated 
through the VSR Equilibrium Platform. 
 
3.3.10 Displacement and velocity of pressure center 
 
Pressure center (COP) is the point and application of ground reaction force in response 
to forces generated by a body in contact with the surface. The COP indicates the trajectory 
displacement of the soil reaction force vector (HAMILL e  KNUTZEN,  2012). The parameters 

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of the COP will be obtained from the displacement and velocity of the center of gravity by 
routine elaborated in MATLAB. The displacement of the COP will be expressed in centimeters 
and the speed of oscillation in centimeters per second. 
 
3.4 INSTRUMENTS 
 
3.4.1 Vicon MX System 
 
The Vicon MX system is a passive system that measures reflected light through markers 
placed on the surface of the human body. This integrated system is indicated for the analysis 
and measurement of human movement, among them the clinical evaluation of gait (VICON 
MX, 2006). 
For the acquisition of the kinematics data of the gait will be used the system Vicon 
Bonita 10 MX Giganet (Oxford Metrics Group; UK) Consisting of 10 beautiful cameras with 
LED emitting component (Light Emitting Diode) that surrounds the lens of each camera, 
maximum frequency of 250 frames per second (fps), 720p and 4-12mm lenses, 11 cables for 
Connect the beautiful cameras to giganet unit. 
All cameras are connected to the Giganet unit, which feeds the cameras and serves as an 
instrument for synchronization and integration with other biomechanical laboratory instruments 
(force platform and electromyography). Once in the video memory, the data is transferred to 
the computer named Nexus® that will perform the processing and reconstruction of the three-
dimensional image of the markers by means of a biomechanical model and mathematical 
algorithms. 
 
3.4.2 AMTI OR6-7 Force Platform 
 
For the study, two AMTI OR6-7 Force Platforms will be used, placed side by side in 
the center of the course where the individual will gait. Each power platform consists of two 
rigid surfaces (top and bottom) interconnected by load cell force sensors. This type of platform 
is a device that has its electrical resistance varied as a function of the mechanical deformation 
of the same (BARELA e DUARTE, 2011). 
The AMTI OR6-7 Force Platform uses four precision-mounted tension gauges to 
measure forces at any given moment. The measurement of the orthogonal force occurs along 

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the X, Y, Z axes and the momentum on these axes, producing a total of six outputs. It has 
vertical capacity to evaluate 4500, 8900 or 17800 Newtons (AMTI, 2010). 
Data sampling will occur at 100Hz. The extended signal will be synchronized with the 
Vicon gait analysis system. 
3.4.3 Noraxon Electromyograph 
 
The electromyographic activation of the lower limb muscles will be measured using the 
Noraxon MyoMuscle v. 3.8. The standard system has EMG preamplifiers, but can be 
synchronized with other biomechanical sensors. In addition it can operate with up to 16 
channels in wireless system, making it easier to capture the signal during the movement. The 
double electrodes are self-adhesive and attached to the sensor, which is attached to the skin with 
double-sided tape. The data collected by the electrode is transmitted immediately to the receiver 
(NORAXON, 2015). The electromyographic data collection will be synchronized to the gait 
collection performed with the Vicon MX System. 
 
3.4.4 Timed up and Go Test (TUG) 
 
The TUG was developed to evaluate the functional mobility of the elderly. The 
classification of the elderly is performed according to the time required to complete the task as 
follows: up to 10 seconds is the time considered normal for healthy, independent adults without 
risk of falls; Between 11-20 seconds is expected for frail or disabled elderly, with partial 
independence and with low risk of falls; Above 20 seconds indicates significant deficit of 
physical mobility and risk of falls (PODSIADLO e RICHARDS, 1991). 
This instrument shows excellent intra-observer and inter-observer reliability (ICC = 
0.99). The concurrent validity was evaluated by comparing it with the Berb Balance Scale (r = 
-0.81), walking speed (Pearson r = -0.61) and the Barthel Index (r = -0.51), presenting a 
Moderate to good correlation between the tests. (PODSIADLO e RICHARDS, 1991). High 
TUG times were significant in predicting the occurrence of falls and decline in ADLs, 
identifying individuals with impaired functional capacity (LIN e WOLLACOTT, 2005). 
 
 
 
 

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3.4.5 Neurocom Balance Platform 
 
The data will be collected using the SMART EquiTest CRS platform and the NeuroCom 
Balance Manager software (NeuroCom International, Inc., Clakamas, OR), which is a 
computerized tool for assessing and managing balance and mobility disorders. 
The SMART EquiTest CRS platform consists of dual force platform, visual 
environment, upper bar with support for the patient harness, LCD monitor for the participant 
and a computer for system operation. 
NeuroCom Balance Manager software measures postural control based on oscillation 
speed, recorded in degrees / second. The calculation used to determine the oscillation speed in 
the SET protocol is not publicly available. According to the interpretation suggested by 
NeuroCom, higher score represents a potential deficit in the balance (NEUROCON, 2010).  
 
3.4.6 Womac Scale (Western Ontario and McMaster Universities Osteoarthritis Index) 
 
The Womac score (ANNEX A) for osteoarthrosis is a valid and reliable instrument, 
specific for knee OA. Evaluates pain, stiffness and physical functions. This questionnaire 
consists of three domains - pain, stiffness and function - and must be answered in relation to 
the intensity of pain, joint stiffness and level of functionality perceived by the individual in the 
last 72 hours. The questions are presented in Likert scale, where each one has a score ranging 
from 0 to 100, thus distributed: 0 = none; 25 = few; 50 = moderate; 75 = intense; 100 = very 
intense. The final score will be obtained by summing the values of all the subjects in each 
question, the average is obtained, and the values are presented for each section or domain 
(IVANOVITH, 2002). 
 
3.4.7 Tampa Scale of Kinesiophobia 
 
Kinesiophobia is defined as excessive, irrational and debilitating fear of movement and 
physical activity, with consequent feeling of vulnerability to pain or fear of relapse of the 
problem. The cover scale for kinesiophobia (APPENDIX B) will be used to quantify fear of 
movement. The validated Brazilian version of the scale will be used. (SIQUEIRA et al, 2007). 
Each instruction is scored on a 4-point Likert scale with scores ranging from 1 "totally disagree" 

13 
 
 
 
to 4 "strongly agree". It presents as possible results the maximum score of 68 points and the 
minimum score of 17 points. The higher the score, the higher the kinesiophobia. 
 
3.5 DATA COLLECTION 
 
The study will be developed in the dependencies of the Laboratory of Biomechanics of 
the Center for Health Sciences and Sports of UDESC. In the preoperative period the subjects 
will be informed about their physical conditions as well as signs and symptoms of the 
postoperative period. One group (GI) will receive this information verbally and one leaflet 
while the other group (GC) will receive only verbal information. The allocation in these groups 
will be through a lottery, carried out by a member of the team who will not participate in the 
evaluation stages. 
This staff member will read the booklet individually for each GI participant, in a 
reserved room, before handing out the leaflet to take home. GI participants will be encouraged 
to reread the information in the home environment and will be asked about the completion of 
this in the following steps by the staff member responsible for the blinding. 
All participants included in the study will perform the kinematic, kinetic and 
electromyographic gait analysis as well as evaluation of fear of movement, functional mobility 
and self-perceived functionality in the pre (baseline)-and postoperative period (6 weeks and 
after 6 months). 
The total duration of  each evaluation will be approximately 2 (two) hours and 30 (thirty) 
minutes and all collections will be carried out by the same team. The participant will be allowed 
to stop the test if they feel pain or become fatigued. The procedures for collecting the data will 
be performed in 5 steps, described below. 
 
3.5.1 Stage 1 - Anthropometric measurements 
 
Body mass and stature will be measured by means of a mechanical scale of up to 150 
kg Filizola® brand, with a resolution of 0.1 kg, and by means of a portable Wiso stadiometer, 
with a resolution of 0.1 cm. The diameters and lengths required for insertion into the 
anthropometric model of kinematic analysis will be measured by a pachymeter and a tape 
measure, both with resolution of 0.1 cm. 
 
 

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3.5.2 Stage 2 – Self-referenced functionality and kinesiophobia 
 
The Brazilian version of the kinesiophobia cover scale and the WOMAC scale will be 
applied before each gait evaluation in the three periods (pre, post 6 weeks and post 6 months). 
 
3.5.3 Stage 3 – gait analysis  
 
The subjects will be previously instructed to wear swimsuits in order to allow the 
placement of the markers in the anatomical points and the reading of the same ones by the 
cameras. All patients will be procedurally oriented and instructed on the tasks to be performed.  
Before each collection, the calibration of the Vicon system will be performed. A T-
shaped metal structure composed of two rods (containing a total of 5 14 mm reflective markers) 
will be used to determine the reference coordinates of the laboratory (X, Y and Z). The dynamic 
calibration will be performed, where the rod will be moved in all planes, generating location 
and orientation data of the cameras inside one. In static calibration the stem will be placed in 
the center of the collection area. Standard deviation errors less than 1 mm between known 
distances between markers. 
Afterwards, thirty-two reflective spherical markers (14 mm in diameter) with double 
faces in specific anatomical points will be fixed in the subject, which will serve as reference for 
the motion analysis capture system. The markers will be placed in the manubrium, xiphoid 
process, seventh cervical vertebra, tenth thoracic vertebra, and bilaterally in the following 
points: acromion, anterior superior iliac spine, posterior superior iliac spine, major femoral 
tuberosity, lateral thigh region, condyle Lateral femoral, medial femoral condyle, fibular head, 
anterior tibial tuberosity, lateral malleolus, medial malleolus, first metatarsal head, fifth 
metatarsal head, and calcaneus. 
Also, the electrodes and WiFi sensors of the Noraxon Electromyograph will be glued 
with double-sided tape on clean skin with cotton soaked in alcohol. The electrodes will be 
positioned on the long head of the femoral biceps, rectus femoris, vastus lateralis and vastus 
medialis following the position recommended by the SENIAM (2016). 
You will be asked to walk on a 5-meter walkway, performing four trials. During the 
course of the gait, the participant must step on each of the lower limbs on one of the AMTI 
force platforms without being aware of this. After the collection, the data will be transported to 
the Visual 3D System, for measurement and analysis. 
 

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3.5.4 Stage 4 – functional mobility assessment 
 
 
 Functional mobility will be evaluated by the timed up and go protocol. A seat with a back 
and without lateral support, a cone and a stopwatch will be used. 
In this protocol the subject will rise from a chair with the backrest resting on the backrest, 
will walk three meters in a straight line, make a 180 ° turn, return to the chair and sit propping 
the backrest on the chair. This course will be timed in seconds and the performance of the 
subject will be graded according to the time spent. The protocol allows you to check the total 
time spent on the task. The subject will perform 3 attempts. The average number of attempts 
will be. 
 
3.5.5 Stage 5 – postural control 
 
The NeuroCom SMART EquiTest CRS balancing platform will be used, with a 
sampling rate of 100 Hz. The equipment will be calibrated according to the manufacturer's 
standards. The collections will be made with three dynamic protocols pre-established by the 
system: Sensory Organization Test (SOT), which verifies the sensory motor control; Motor 
Control Test (MCT), which verifies the automatic motor control; And Adaptation Test (ADT), 
which verifies adaptive motor control. 
All protocols will be performed in the bipodal position, where the individual will 
position their feet together, parallel, hands along the body and face facing forward. The tests 
performed will evaluate the posture control of the participant in static posture with open and 
closed eyes, without and with movement of the support surface and / or visual environment. 
The order of the three protocols (SOT, MCT and ADP) will be chosen by lot. 
During collection the individual should stand at the base of the platform looking 
forward. He will wear harness (available in small, medium and large size) connected to safety 
cables throughout the test. During the test only the presence of the evaluator and one other 
member of the collection team will be allowed to assist the assessor in case of loss of balance. 
Both should be close to the individual, but should not interfere with the test. 
You will be prompted to look at the screen in front of you and center the puppet 
(corresponding to the alignment of the participant). Before starting the tests the individual will 
be informed that the platform and the environment can move during the evaluation, but will not 
be informed about when this will occur. Afterwards, the researcher will start collecting the data, 

16 
 
 
 
guiding the participant to keep the doll as centralized as possible without flexing the knees or 
changing the position of the feet. In cases where the participant uses these or other artifacts to 
maintain postural control (eg, hold in the environment), the test will be considered a "failure" 
and the test will continue for the next test.  
 
Figura 1 – Data collection procedure diagram 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.6 ANÁLISE DOS DADOS 
 
After the draw, they were 
allocated to the intervention 
group (n=  ) 
Loss of follow-up (give reasons) (n =) 
Discontinued intervention(give reasons) (n=  ) 
After the draw, they were 
allocated to the control 
group (n=  ) 
Analyzed (n =) 
Excluded from analysis (give reasons) (n=  ) 
Allocation 
Analysis 
Follow-up 
Loss of follow-up (give reasons) (n =) 
Discontinued intervention(give reasons) (n=  ) 
Analyzed (n =) 
Excluded from analysis (give reasons) (n=  ) 
Inclusion criteria: age over 55 years; Literate; Elective submission of total unilateral knee 
arthroplasty (TKA) due to osteoarthrosis; Who have not performed anterior unicompartmental 
replacement or tibial osteotomy in the same knee; Who have not had a knee infection or other 
serious complications after TKA; Body mass index less than 40 kg / m2; Who has not had other 
arthroplasties in the lower limb in the last 6 months; Bow of movement greater than 90º in the 
operated or contralateral knee. (n =  ) 
Excluded (n =): associated condition that 
impedes gait tests performance, lack or 
abandonment in the study follow-up 
sessions. 
Randomized (n=  ) 
Inclusion 

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The data collected in the preoperative period will be used as a comparative baseline to 
determine changes in gait parameters (spatio-temporal, kinetic, electromyographic), postural 
control and functionality associated with the presence or absence of information in the 
preoperative. 
Self-perceived functionality, fear of movement and TUG time will be exported to 
spreadsheet in EXCEL software for further statistical analysis. 
The gait analysis data will be analyzed in the Vicon-Nexus software, version 2.1.1, 
through a processing routine that will include filtering and application of the algorithms. In this 
analysis, frontal (adduction / abduction of the knee) and sagittal (knee flexion / extension) 
planes will be considered. In addition, the following space-time parameters will be recorded 
during the run: (1) step length in centimeters; (2) stride length in centimeters; (3) symmetry of 
the foot; (4) step and step time in seconds; (5) single and double support time in seconds and 
(6) the knee adductor moment in response to the load. 
The coefficient of variation (CV = standard deviation of pitch duration / average pitch 
duration x 100%) will be calculated to indicate the individual variability in pitch duration. 
  The raw electromyographic signals will be processed to obtain the linear envelope 
following the steps of full wave rectification, filter smoothing with 4th order Butterworth and 
cutoff frequency of 5Hz. The amplitudes of the linear envelopes will be normalized by the 
maximum voluntary contraction in each muscle (YANG e WINTER, 1984). 
The total time to perform the functional mobility task (TUG) will be set in excel for 
further analysis. 
  In the evaluation of postural control, the velocity of oscillation of the center of gravity 
(in degrees per second) in the six conditions, bipodal support, unipodal support and tandem, 
both on stable and unstable surfaces will be evaluated. The center of gravity velocity data will 
be processed in a Matlab routine, where the displacement data (cm) and velocity (ms) of the 
pressure center (COP) will be extracted in the anteroposterior and mediolateral directions. 
 
 
3.8 MAIN SCIENTIFIC CONTRIBUTIONS OF THE PROPOSAL 
It is hoped that, once the hypothesis of the benefit of preoperative guidance in the form 
of a leaflet on the level of kinesiophobia and functionality of individuals submitted to knee 
arthroplasty is confirmed, health professionals can use this resource in order to promote Better 
results for these individuals. 

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In addition, in the case of a null hypothesis, the cross-evaluation of the data collected at 
the different moments of the study and between the participants may lead to the formulation of 
new guidance and / or approaches that may benefit such variables in this public (level of 
kinesiophobia and functionality). 
 
REFERENCES 
 
Alnahdi AH, Zeni JA, Srydler-Mackler L. Gait after unilateral knee arthroplasty: frontal plane 
analysis. J Orthop Res. 2011 May; 29(5): 647–652. 
 
Athwal KK, Hunt NC, Davies AJ, Dehaan DJ, Amis AA. Clinical biomechanics of instability 
related to total knee arthroplasty. Clinical Biomechanics. 2014, 29: 119–128. 
 
Aydin D, Klit J, Jacobsen S, Troelsen A, Husted H. No major effects of preoperative 
education in patients undergoing hip or knee replacement – a systematic review. Dan Med. 
2015, jul, 62(7): 1-5. 
 
Baliza GA, Lopes RA, Dias RC. O papel da catastrofização da dor no prognóstico e 
tratamento de idosos com osteoartrite de joelho: uma revisão crítica da literatura. Rev. Bras. 
Geriatr. Gerontol. 2014; 17(2):439-449.  
 
Barela AMF, Duarte M. Utilização da plataforma de força para aquisição de dados cinéticos 
durante a marcha humana. Brazilian Journal of Motor Behavior, 2011, Vol. 6, No. 1, 56-61. 
 
Casartelli NC, Item-Glatthorn JF, Bizzini M, Leunig M, Maffiuletti NA. Differences in gait 
characteristics between total hip, knee, and ankle arthroplasty patients: a six-month 
postoperative comparison. BMC Musculoskeletal Disorders. 2013, 14:176. 
 
Fernandes, M.I., Ferraz, M.B., Ciconelli, R.M., 2003. Tradução e Validação do Questionário 
de Qualidade de Vida Específico para Osteoartrose (WOMAC) para a Língua Portuguesa. 
Rev Paulista Reumatol. 10, 25. 
 
Garbossa A, Maldaner E, Mortari DM, Biasi J, Leguisamo CP. Efeitos de orientações 
fisioterapêuticas sobre a ansiedade de pacientes submetidos à cirurgia de revascularização 
miocárdica. Rev Bras Cir Cardiovas.  2009; 24(3): 359-366. 
 
Giesinger JM, Hamilton DF, Jost B, Behrend H, Giesinger K. WOMAC, EQ-5D and Knee 
Society Score Thresholds for Treatment Success After Total Knee Arthroplasty. The Journal 
of Arthroplasty. 2015,  30: 2154–2158. 
 
Gonçalves M, Silva SRD. Análise de variáveis eletromiográficas durante contração isométrica 
fadigante. Salusvita. 2007, 26(1): 39-51. 
 
Hall SJ. Biomecânica básica. Rio de Janeiro. Guanabara Koogan, 2013. 
 

19 
 
 
 
Hallal CZ, Marques NR, Spinoso DH, Karuka AH, Cirqueira RT, Crozara LF, Morcelli MH, 
Gonçalves M. Variabilidade eletromiográfica dos músculos dos membros inferiores de idosas 
ativas durante a marcha com dupla tarefa antes e após treinamento de equilíbrio com haste 
vibratória. Ter Man. 2013, 11(52): 241-247. 
 
Hamill J, Knutzen KM. Bases Biomecânicas do Movimento Humano. 3ª edição. Manole, São 
Paulo, 2012. 
 
Hulley SB, Cummings SR, Browner WS, Grady  DG, Newman TB. Delineando a pesquisa 
clínica. 4ª edição. Artmed, Porto Alegre, 2015. 
 
Hyiama Y, Asai T, Wada O, Maruno H, Nitta S, Mizuno H, Iwasabi Y, Okada S. Gait 
Variability before Surgery and at Discharge in Patients Who Undergo Total Knee 
Arthroplasty: A Cohort Study. Plos One. 2015, jan 24: 1-8. 
 
Ivanovith MF. Tradução e validação do questionário de qualidade de vida específico para 
osteoartrose WOMAC (Wester Ontario and McMaster Universities) para a língua portuguesa. 
[Tese]. São Paulo (SP): Universidade Federal de São Paulo; 2002. 
 
Lee A, Park J, Lee S. Gait analysis of elderly women after total knee. Arthroplasty. J Phys 
Ther Sci 2015, 27: 591–595. 
 
Lin S, Woollacott M. Association between sensorimotor function and functional and reactive 
balance control in the elderly. Age and Ageing 2005; 34: 358–63. 
Louw A, Diener I, Butler DS, Puentedura EJ. Preoperative education addressing postoperative 
pain in total joint arthroplasty: Review of content and educational delivery methods. 
Physiotherapy Theory and Practice. 2013, 29(3):175–194. 
 
McNamara I, Birmingham TB, Fowler PJ. High tibial osteotomy: evolution of research and 
clinical applications—a Canadian experience. Knee Surg Sports Traumatol arthrosc. 2013, 
21:23–31.  
 
Milner CE. Is gait normal after total knee arthroplasty? Systematic review of the literature. J 
Orthop Sci. 2009, 14:114–120. 
 
Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps strength and the time course of 
functional recovery after total knee arthroplasty. J Orthop Sports Phys Ther. 2005a;35:424–36 
 
Monticone M, Ferrante S, Rocca B, Salvaderi S, Fiorentini R, Restelli M, Foti C. Home-
Based Functional Exercises Aimed at Managing Kinesiophobia Contribute to Improving 
Disability and Quality of Life of Patients Undergoing Total Knee Arthroplasty: A 
Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. 2013, 
94:231-9. 
 
Myomuscle EMG. User Guide v3.8. Noraxon, USA, 2015. 
 
OR6-7 Force Platform. AMTI Force and Motion, USA, 2010. 
 
Perry J. Análise de marcha, vol 3: Sistemas de Análise de Marcha. São Paulo. Manole, 2005. 
 

20 
 
 
 
Podsiadlo D, Richards S. The Timed ‘Up & Go”: a test of basic functional mobility for frail 
elderly persons. J Am Geriatr Soc. 1991; 39 (2): 142-48. 
 
Salvato KF, Santos JPM, Pires-Oliveira DAA, Costa VSP, Molari M, Fernandes MTP, Poli-
Frederico RC, Fernandes KBP. Análise da influência da farmacoterapia sobre a qualidade de 
vida em idosos com osteoartrite.  Rev Bras Reumatol. 2015; 55 (1): 83-88. 
 
Santos MLAS, Gomes WF, Queiroz BZ, Rosa NMB, Pereira DS, Dias JMD, Pereira LSM. 
Desempenho muscular, dor, rigidez e funcionalidade de idosas com osteoartrite de joelho. 
Acta Ortop Bras. 2011;19(4): 193-7.  
Siqueira FB, Terexeira-Salmela LF, Magalhaes LC. Analysis of the Psychometric properties 
of the Brazilian version of the Tampa Scale of Kinesiophobia Acta Ortop Bras. 2007, 15: 19–
24. 
 
Seniam – Surface ElectroMyoGrapgy for the Non-Invasive Asssessment of Muscles. 
Disponível em < http://www.seniam.org/> acessado em 04 de novembro de 2016. 
 
Sistemas Balance Manager: Instruções de uso. NeuroCom® International, Inc. Clackamas, 
Oregon (EUA), 2010. 
 
Vasconcelos JW, Leite LMS, Sousa JCA, Sousa JOM, Santos MFS. Avaliação em médio 
prazo da artoplastia total de joelho sem substituição da patela. Rev Bras Ortop. 
2013;48(3):251-256. 
 
Vicon MX Hardware System Reference: revision.  1.4. Oxford, 2006. 
 
Villardi AM, Veiga LT, Franco JS, Cagy M, Silva PJG, Raptopoulos L, D’Angelo MA. 
Análise da marcha pós-artroplastia total do joelho com e sem preservação do ligamento 
cruzado posterior. Rev Bras Ortop. 2005, 40(6): 316-330. 
 
Yaari L, Kosashvili Y, Segal G, Shemesh S, Velkes S, Mor A, Debi R, Bernfeld B, Elbaz A.  
A Novel Non-Invasive Adjuvant Biomechanical Treatment for Patients with Altered 
Rehabilitation after Total Knee Arthroplasty: Results of a Pilot Investigation. Clinics in 
Orthopedic Surgery. 2015, 7:191-198. 
 
Yang JF, Winter DA. Electromyographic amplitude normalization methods: improving 
sensitivity as diagnostic tools in gait analysis. Arch Phys Med Rehabil. 1984;65:517-21. 
 
Yuksel E, Kalkan S, Cekmece S, Unver B, Karatosun V. Assessing Minimal Detectable 
Changes and Test-Retest Reliability of the Timed Up and Go Test and the 2-Minute Walk 
Test in Patients With Total Knee Arthroplasty. The Journal of Arthroplasty. 2016: 1-5.  
 
 
 

21 
 
 
 
 
APPENDICES 
 
APPENDIX A - Guidance for Patients with Total Knee Arthroplasty 
 
The knee is a joint composed of three bones: femur, tibia and patella. Between the 
femur and the tibia there is a kind of cushion, the cartilage. In a healthy knee, these structures 
also distribute body weight and allow the movements needed to walk. 
Aging can result in wear and tear on this joint, it is osteoarthritis. When the knee 
becomes very sore and does not move more, it is necessary to change the joint to relieve pain 
and return the movements to perform daily activities (sitting, walking, climbing and descending 
stairs). This exchange is done by surgery, called ARTHROPLASTY. 
In knee arthroplasty, the bones (tibia and femur) are replaced with very resistant 
metal. The patella is replaced by a kind of sturdy plastic. 
  This surgery is performed by a specialized and well trained team and requires 
special care in the postoperative period. Adequate observation and care also prolong the use of 
the prosthesis as much as possible. Thus, this guide will present some clarifications in order to 
enable a faster and better recovery for you as well as better use of surgery. 
 
BEFORE SURGERY 
If you have crutches or walkers, do not forget to take them. Will be useful after 
surgery. 
Also remember to take your preoperative exams, including x-rays. The surgery time 
varies with each case and will be informed by the doctor, but may suffer increases for various 
reasons without the need for concern of family members. 
 
DURING THE SURGERY 
The best anesthesia for you will be chosen by your anesthesiologist. 
The surgery cut is done in front of the knee, after removing the damaged bone part 
and placing the prosthesis. At the end of surgery may be placed drain and dressing that remain 
for 48 hours. 
 
 
 

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AFTER SURGERY 
Once the anesthetic effect has passed, you will go to the hospital bed and the pain 
will be controlled with medication. 
The physiotherapy team will guide you on how to move in bed and when to start 
walking. 
On the day of discharge we hope that you can already sit, walk with the help of 
crutches or walker and leave the hospital sitting in the passenger seat with the stretched operated 
leg. 
 
POSTOPERATIVE GUIDANCE 
In the postoperative the objective is to improve the strength, to minimize swelling 
and to obtain total movement of the operated leg. 
DOUBLE AND STRETCH the leg throughout the day. Please follow correctly the 
recommendations and exercises passed by the team (doctors, nurses and physiotherapists). 
 In the first 12 hours after surgery you CAN NOT support the operated limb on the floor, 
so when sitting on the bed they should be loose. 
 You may have PAIN after surgery, even so let the team know. 
 BLEEDING and HEMATOMA may occur after surgery, but do not worry, they slowly 
disappear. 
 AVOID lying on the operated legNÃO COLOQUE TRAVESSEIRO embaixo do joelho 
operado. Tente deixa-lo esticado quando estiver deitado. 
 When standing, divide the weight of the operated leg with the crutches and the other 
leg. 
 PLACE ICE on the knee with the leg elevated. Do this at least 3 TIMES a day. 
 REMOVE THE CARPETS from the house. LOOK WHERE IT PISA! USE shoes with 
non-slip sole. 
 You CAN HAVE SLEEP AND Stiffness in the knee, especially when folding your knee 
a lot, for example when sitting and getting up from a low chair or car seat. 
 ATTENTION IN THE BATH in the first few days. TAKE INTO THE SEATING 
POSITION for added safety. 
 In the first month, AVOID POSITION SITTING FOR MORE THAN 45 MINUTES. 
Alternate sitting with walking. 

23 
 
 
 
 When sitting, it is important to bend the knee and remember not to leave the limb hard 
to walk. This will make it easier to move and give you more comfort. 
 Kneeling is not harmful but may cause noise due to the material of the prosthesis. 
 To UP STAIRS use FIRST NON-OPERATED MEMBER after limb operated and lastly 
the crutch. 
 To lower LADDERS, place FIRST BALL, then MEMBER OPERATED and last 
member not last operated. 
 SPORTS ACTIVITIES only after TOTAL KNEE RECOVERY. 
 The intercourse is safe between 4 and 6 weeks, but its beginning depends on care as 
well as other daily activities. 
 To drive you should no longer be taking medication for pain and need to have the release 
of your doctor. 
 Over the weeks the possible distance of walking gradually increases as well as the 
improvement of the other symptoms. The total benefits of joint replacement usually 
occur between 6 and 8 months postoperatively. 
 
 
 
 
 
 
 
 
 

24 
 
 
 
APPENDIX C - Personal data and follow-up of participants 
 
MASTER IN PHYSIOTHERAPY 
Preoperative guidance and repercussion in gait after 
knee arthroplasty 
 
Name:  
 
 
 
 
 
 
 
         Sex: (  )F (  ) M 
Date of birth / age: 
 
__________ 
 
     
Telefone: (  ) 
 
 
Address:   
 
 
 
 
 
 
 
 
 
 
Date of surgery:   
        
Weight:  
 
 
Height:  
 
 
Anterior surgeries in the operated or contralateral knee: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physiotherapeutic Treatment 
PREOPERATIVE - Allocation (  ) GI   (  ) GC 
Do you do physiotherapy for your knee pain? If yes, how many times in the week? _____ 
What treatment time (weeks, months, years)? _____________________________ 
Check the type of procedures you perform in the sessions: 
( ) warmth ( ) cold ( ) TENS ( ) US ( ) stretches ( ) strengthening exercises ( ) balancing 
exercises ( ) Others, which ones? _____________________________________________ 
 
 
6 WEEKS AFTER SURGERY - Booklet reading  (  ) Yes   (  ) No  (  )GC 
Are you doing physiotherapy? If yes, how many times in the week? _________________ 
How long after the surgery did you start the sessions? ____________________________ 
If completed, how many sessions and for how long? ______________________________ 
Check the type of procedures you perform in the sessions: 
( ) warmth ( ) cold ( ) TENS ( ) US ( ) stretches ( ) strengthening exercises ( ) balancing 
exercises ( ) Others, which ones? _____________________________________________ 
 
 
6 MONTHS AFTER SURGERY - Booklet reading  (  ) Yes   (  ) No  (  )GC 
Are you doing physiotherapy? If yes, how many times in the week? _________________ 
How long after the surgery did you start the sessions? ____________________________ 
If completed, how many sessions and for how long? ______________________________ 
Check the type of procedures you perform in the sessions: 
( ) warmth ( ) cold ( ) TENS ( ) US ( ) stretches ( ) strengthening exercises ( ) balancing 
exercises ( ) Others, which ones? _____________________________________________ 
 
 
 
 

25 
 
 
 
ATTACHMENTS 
 
ATTACHMENT A – WOMAC (Western Ontario and McMaster Universities Osteoarthritis 
Index) 
 
 
 
 
 

26 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

27 
 
 
 
ATTACHMENT B –TAMPA SCALE OF KINESIOPHOBIA