Class format to improve the management of total knee replacement in an out-patient setting


Historically patients at North Manchester General Hospital received traditional 1:1 Physiotherapy treatments post total knee replacement (TKR). Literature suggests a class environment can be more cost effective and yield improved results. Therefore a TKR class was set up in 2015. This summary highlights the findings from the first year demonstrating clinical outcomes, patient satisfaction and cost-effectiveness.

100% client satification
with the new class format
4 more patients
seen in the class environment per week


This was a retrospective study reviewing patient notes for specific study details.  Patients who had completed and were discharged from the 6 week class were included. The class is a 6 week rolling programme run by 2 physiotherapists over a 2 hour period each week at NMGH physiotherapy department. Patients attend at staggered intervals taking approximately 30 minutes to complete a circuit consisting of 10 different lower limb exercises focusing on strength, range of motion, balance training and gait re-education. The exercises are tailored and progressed according to individual need.

Outcome measures were performed for the first 50 patients to attend the group. Data were collected on class entry and discharge evaluating range of movement (ROM), functional status (WOMAC) and patient satisfaction (CSQ-8UK). In addition the cost-effectiveness of the class was explored in terms of staff resources and number of patient appointments. Where available, comparisons were made with 1:1 traditional physiotherapy treatments.


Class Mean ROM week 1: 9-83 degrees; Class Mean ROM week 6: 0-105 degrees.
1:1 Mean ROM week 1: 10-80 degrees; 1:1 Mean ROM week 6: 0-103

Mean WOMAC week 1: 42; Mean WOMAC week 6: 25
Unfortunately, no WOMAC scores were collected for 1:1 patients. However, anecdotally the physiotherapists feel patients attending the class demonstrated improved levels of general fitness and function compared to individual treatment.

Patient Satisfaction
The CSQ-8UK scores range from 8- 32, with the larger number revealing higher levels of client satisfaction. The average score was 32 indicating excellent client satisfaction.
Data was not available for 1:1 treatments. However, some patients who had previous experience of attending 1:1 physiotherapy treatments expressed a preference for the class format.

Main findings were that the AROM was better with patients attending the TKR class.  Unfortunately no WOMAC available for comparison with 1:1, but class WOMAC scores significantly improved by week 6. From a patient perspective they found it useful to have continuity with the same Physiotherapists each week also.  They also reported that they found the class environment more supportive and motivating.  They enjoyed that the class took place in a gym setting; it was well equipped for their rehabilitation classes and felt this aided their rehab.

Cost and savings

Class average attendance: 16 patients
1:1 attendance over the same 2 hour period: 12 patients

There was no additional cost to setting up the project as the research into the project and setting up was all conducted within normal working hours.

There was an increase in both productivity and efficiency seen through implementing the class, as on average 4 more patients were seen in the class environment per week.


From our audit the TKR class was more cost effective and patient satisfaction was excellent.  This means that more patients are able to access Outpatient Physiotherapy via the class in comparison with 1:1 appointments over a 2 hour time period. The class can accommodate an extra 4 patients.  This equates to 80 minutes of Physiotherapy time available for other 1:1 appointments, which allows for 1 new patient and a follow up Physiotherapy appointment each week.  This is another measure to help with waiting list initiatives.

The implementation of the new class format for TKR patients has demonstrated it to be a cost-effective clinical resource in terms of saving physiotherapy appointments.
Comparisons with 1:1 physiotherapy revealed the mean ROM improved equally regardless of treatment format.
The class demonstrated a clinically significant improvement in functional status as measured by the WOMAC tool.
100% of the patients indicated excellent client satisfaction with the new class format.

Physiotherapists at NMGH can be confident that switching to a class format can maintain or enhance clinical outcomes and patient satisfaction whilst saving physiotherapy appointments.

Top three learning points

  • Important to review current practice to look at innovative ways of delivering care.
  • Good to liaise with local departments to see how they have implemented change.
  • One change in service delivery can have a positive impact both for patients and the practical delivery of the service itself.

Funding acknowledgements

No funding was required for this service development.

Additional notes

This work was presented at Physiotherapy UK 2017.