Hiyama, Y., Kamitani, T., Wada, O., Mizuno, K., Yamada, M. (2016) Journal of Orthopedic and Sports Physical Therapy, 46(9), 742-748.

Article summary by Jessica Reid, SPT from Missouri State University, Springfield, MO.

Hiyama and colleagues performed a prospective observational study with a historical control group to explore the effects of group therapy sessions on knee range of motion, quadriceps strength, functional ability, and pain in patients acutely after a total knee arthroscopy (TKA).  231 patients met the inclusion criteria for the group exercise (G-EXE) experimental group and 206 patients fit the same criteria for the individual exercise (I-EXE) control group.  Although the historical control group received their TKA within the year prior to the G-EXE group, Hiyama et al ensures that the large sample size, in addition to identical surgical, anesthetic, and post-surgical procedures, reduced the variability in group characteristics.

The inclusion criteria included: (1) age between 50 and 80 years and (2) completion of primary unilateral TKA for stage 4 knee osteoarthritis (OA) determined via Kellgren-Lawrence radiographic grading system.  Furthermore, the exclusion criteria consisted of: (1) uncontrolled hypertension, (2) neurologic impairments, (3) coexisting OA or other orthopedic impairments in the contralateral hip or knee affecting mobility, and (4) rheumatoid arthritis.  

Each patient performed 20 minutes of ambulation activities and activities of daily living (ADLs) twice a day beginning the day after surgery and continuing until the day before discharge.  These activities included transfer training, ambulation using a walker while weight bearing as a tolerated, and ascending/descending stairs.  The ultimate mobility goal was to ambulate independently using a cane by discharge; exercises were progressed accordingly.  In addition to functional activities, both groups of patients participated in 30-minute sessions consisting of: 15 minutes of ice massage, 15 repetitions of ankle pumps, hip rotations without load, quadriceps setting without load in a neutral hip position, and active-assisted heel slides in long-sitting.  Both the I-EXE and the G-EXE groups completed the same exercises and activities for the same amount of time each day; however, the I-EXE group did all activities and exercises individually and the G-EXE performed the 30-minute session in groups of six patients.  

At discharge, patients from the G-EXE group demonstrated greater knee range of motion (+6.0 degrees of knee flexion, +5.0 degrees of knee extension), stronger quadriceps (+0.21 Nm/kg), and reported less pain than the I-EXE group (-2.0 on a 10 point scale).  Regarding functional mobility, the timed up-and-go (TUG) test showed no significant difference between the G-EXE and I-EXE groups.  Lastly, Hiyama et al observed that the mean length of stay for the G-EXE group (6.9 ± 0.4 days) was significantly shorter than the I-EXE group (7.9 ± 0.8 days).  

Hiyama et al reported that the majority of previous studies comparing group exercise to individual therapy sessions displayed little or no effect.  However, these previous studies had low patient attendance rates and poor patient adherence.  This particular study has demonstrated that with 100% patient adherence, group-based therapy sessions have the possibility of positively affecting patient outcomes.

Personal Commentary  

Practicing clinicians are continuously searching for efficient interventions and techniques that effectively provide greater patient outcomes.  However, even when the evidence portrays these results, healthcare professionals must take finances and reimbursement potential into account.  Previously, physical therapists commonly avoided group therapy either because the reimbursement rate was far lower than individual therapy sessions or because they may not be reimbursed at all.

With the implementation of the bundled payments system, this may change how healthcare professionals view group therapy.  Firstly, the reimbursement rate does not change if a patient receives individual therapy or group therapy – the bundled payment that the facility receives per patient remains the same.  Although this possibly opens the door for dishonest clinicians to abuse the system, this could assist in improving time management and overall productivity statistics for physical therapists.  Additionally, Hiyama et al has shown that the patients’ length of stay for post-surgical acute care was significantly decreased.  Furthermore, the patients were discharged with improved range of motion, strength, and decreased pain which may increase the likelihood of the patient being discharged to home – rather than a rehabilitation or skilled nursing facility.  Both of these factors can potentially lead to an overall decrease in the cost of a TKA.  This lower cost of healthcare services benefits all stakeholders involved.  

The question still remains about the mechanism for how group therapy leads to improved outcomes.  Deforche and De Bourdeaudhuij explored the idea of psychosocial benefits of group activities versus individual activities, in which they found that group exercise did indeed provide this benefit to elderly adults.  More specifically, there are queries regarding the competitive aspect of group therapy.  Overall, with the current evidence, group-based therapy sessions seem favorable in all aspects.  


  1. Hiyama, Y., Kamitani, T., Wada, O., Mizuno, K., Yamada, M. (2016) Effects of Group-Based Exercise on Range of Motion, Muscle Strength, Functional Ability, and Pain During the Acute Phase After Total Knee Arthroscopy: A Controlled Clinical Trial. Journal of Orthopedic and Sports Physical Therapy, 46(9), 742-748.
  2. Deforche B, De Bourdeaudhuij I. Differences in psychosocial determinants of physical activity in older adults participating in organised versus non- organised activities. J Sports Med Phys Fitness. 2000;40:362-372.