Knee osteoarthritis (OA) is one of the most common joint problems in the world, affecting millions of people globally. It's a condition in which the cartilage–the smooth, protective tissue covering the ends of bones in your knee–starts to break down. This leads to pain, stiffness, swelling, and problems with walking or climbing stairs. For many individuals, daily activities become a challenge, and their quality of life takes a hit. According to recent statistics, knee OA affects approximately 10% of men and 13% of women over the age of 60, which makes it a leading cause of disability among older adults.

When knee pain from OA becomes severe and other interventions fail to provide adequate relief, a surgical procedure called a total knee replacement–or total knee arthroplasty (TKA)–is often considered as the next step. In fact, over 50% of patients with knee OA will eventually undergo a TKA in their lifetime. Doctors know that when patients participate in a comprehensive physical therapy program before the procedure–called prehabilitation or “prehab” for short–outcomes are typically better, but what's less clear is how intense the treatment should be at this stage. With this in mind, a team of researchers conducted a study to find out.

Two slightly different approaches to prehab

You might be asking, “Why focus on what happens before surgery?” The answer lies in the concept of “prehabilitation” or “prehab.” Think of it like training for a big race: if you start running and strengthening your muscles well before race day, you're far more likely to perform at your best. The same applies to knee surgery. By preparing your muscles and joints with intense preoperative therapy, your body will be better equipped to handle the trauma of surgery and recover faster.

But prehab isn't a single, one–size–fits–all program. Most patients are offered some form of preoperative physical therapy to build strength and prepare for surgery, but the intensity can vary. Two general approaches to prehab are the following:

Conventional therapy training (CTT)

• This traditional approach focuses on low– to moderate–intensity exercise. Sessions include light resistance training, gentle stretching, and balance drills. The goal is to maintain muscle tone, improve flexibility, and help patients stay active before surgery.

Intensive therapy training (ITT)

• Sometimes called high–intensity prehab, this option ramps things up. It features progressive resistance exercises, multiple sets of strengthening moves, endurance workouts on equipment like stationary bikes or treadmills, and more challenging balance activities. Sessions are longer, more frequent, and carefully supervised by physical therapists to safely push patients' strength and stamina.

Intensive prehab comes out on top in head–to–head analysis

Both CTT and ITT aim to give patients a “head start” before knee replacement, but the verdict is still out on which style of prehab leads to better results. With this in mind, researchers conducted a comprehensive study called a systematic review and meta–analysis that was designed to identify and analyze all relevant studies evaluating preoperative CTT and/or ITT before knee surgery. This search led to seven clinical trials with 490 participants being included in the review. All patients underwent a TKA and completed a prehab program beforehand, with some following a conventional program and others completing a higher–intensity regimen. The researchers then reviewed the findings of these studies to compare outcomes like walking distance, muscle strength, knee motion, and quality of life.

Patients who underwent ITT before surgery showed clear advantages over those who completed a CTT program in the following outcomes:

• Walking distance: on six– and ten–minute walk tests, the ITT group was able to walk about 45 m (about 148 ft) further than the CTT group


• Muscle strength: strength of the quadriceps muscles in the thigh increased more with ITT than CTT


• Range of motion: ITT participants gained better knee flexion, meaning they could bend the knee more easily


• Daily function and quality of life: scores on the WOMAC (a measure of pain and function) and the SF–36 physical health survey were higher in the intensive group


• Mobility tests: participants in the ITT group climbed stairs faster and performed better on the Timed Up and Go test than the CTT group, which measures agility and fall risk

The CTT group was found to have slightly better isometric knee extension strength than the ITT group, but this was the only measurement in which outcomes were superior in this group, as the intensive prehab consistently demonstrated broader functional improvements overall.

These findings show that patients who participated in intensive pre–surgical therapy experienced marked improvements in walking ability, quadriceps strength, and overall mobility compared to those who only followed standard, lighter programs. In short, more focused, rigorous therapy before surgery can set the stage for a smoother, faster recovery.

How we can help with both pre– and post–surgery rehab matter

This research makes one thing clear: starting physical therapy before surgery can set you up for success, but that's only half the story. The best outcomes occur when patients continue with a structured rehabilitation plan after knee replacement as well. An intensive prehab program helps you enter surgery stronger and more flexible, while a carefully guided postoperative plan rebuilds strength, restores full motion, and keeps scar tissue from limiting your progress. Together, these two phases work like a one–two punch, helping you get back to walking, climbing stairs, and enjoying daily activities faster and with less pain.

We offer comprehensive care at our clinic for both the period before and after total knee replacement procedures. Our licensed physical therapists can design individualized prehab programs to prepare your muscles and joints, then transition you seamlessly into post–operative therapy once your surgeon clears you. From progressive strengthening to hands–on manual therapy and tailored home exercises, we'll guide you every step of the way of your recovery.

So if knee replacement is in your future–or if you've recently had surgery–contact us today to schedule an evaluation and start your personalized pre– and post–surgery rehabilitation plan.

Or if you'd like to read more about the research behind these recommendations, click here for the full study.