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Rehabilitation after Knee Replacement

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About Knee Replacement Rehabilitation

Knee replacement rehabilitation refers to the structured, progressive rehabilitation provided following primary total knee arthroplasty (TKA) to restore mobility, function, and participation in daily life. While knee replacement is performed to reduce pain and improve quality of life in people with advanced knee osteoarthritis, surgical success alone does not determine outcomes. Functional recovery is largely dependent on the timing, quality, and continuity of rehabilitation.

Post-operative recovery involves predictable physiological changes, including pain, swelling, reduced range of motion, muscle inhibition, gait impairment, and reduced physical capacity. Without appropriate rehabilitation, these impairments may persist and contribute to delayed recovery, long-term functional limitation, and dissatisfaction despite technically successful surgery.

Rehabilitation following knee replacement is typically phased, progressing from early post-operative recovery and mobility restoration to strength, endurance, and functional retraining. Care may occur across multiple settings (acute care, inpatient rehabilitation, outpatient or community-based care, and home-based programs) and should be coordinated to support safe transitions and sustained engagement.

This care pathway focuses on conservative, rehabilitation-led management after primary knee replacement. It emphasizes patient-centred care, shared decision-making, and outcomes that matter to individuals, including function, participation, and quality of life. The pathway does not address surgical technique, implant selection, or revision knee arthroplasty.

Rehabilitation following knee replacement is supported by a clinical practice guidelines and systematic reviews. Evidence consistently demonstrates that exercise-based rehabilitation, education, and early mobilization are core components of effective care, while the optimal mode and setting of delivery should be tailored to individual needs, goals, and context.

This pathway is intended to guide clinicians, health systems, and policy-makers in delivering safe, effective, and equitable rehabilitation following knee replacement, while allowing flexibility to accommodate individual recovery trajectories and local care models.

About CCG Care Pathways

Purpose

CCG is a knowledge translation resource of the Canadian Chiropractic Association. Its care pathways help chiropractors and other clinicians organize conservative care for musculoskeletal conditions. Each pathway outlines the main steps of the clinical encounter and supports decisions about assessment, care, monitoring, referral, co-management, and discharge. The pathways provide a structured approach to care, not a fixed prescription.

Development

Pathways draw on relevant clinical practice guidelines, systematic reviews, peer-reviewed literature, and safety or professional sources. These sources inform, but do not determine, pathway content. Their findings reflect the questions, populations, outcomes, methods, and judgments used and may not apply to every person. Condition-specific sources are identified by author or organization and year, with full citations in one reference list at the end of the pathway.

Principles of Care

Musculoskeletal conditions are shaped by physical, psychological, social, cultural, and environmental factors, so no single approach fits everyone. Good care is ethical, evidence-informed, person-centred, culturally responsive, and tailored to the patient’s goals, preferences, circumstances, and response. Shared decision-making and informed consent guide care. Education, active rehabilitation, and self-management support recovery, functioning, participation, and long-term health. Regular reassessment shows whether the plan is helping and when to continue, adapt, stop, refer, co-manage, or discharge.populations.

Pathway Flow at a Glance

The pathway follows a recurring clinical cycle: understand the person and their goals; screen for safety and referral needs; develop a working clinical profile; agree on a plan and relevant outcomes; provide care; reassess response and safety; and continue, adapt, stop, refer, co-manage, or discharge as appropriate.

Disclaimer

CCG care pathways support professional clinical judgment; they do not replace it or the advice of a qualified provider. They are not prescriptive, authoritative, or regulatory and are not intended for diagnosis or billing. Clinicians remain responsible for practicing within their competence and scope, meeting applicable legal and regulatory requirements, obtaining informed consent, recognizing emergencies, and arranging referral or co-management when needed.

Knee Replacement Rehabilitation Care Pathway

1. Record Keeping

Accurate, timely, and sufficiently detailed documentation supports safe, high-quality care. The record should reflect clinically relevant patient interactions, clinical reasoning, decisions, care provided, and progress over time. Documentation should meet the legal, regulatory, privacy, retention, and organizational requirements that apply where the clinician practices. A structured format, such as SOAP, may support consistency, clarity, and continuity and can be adapted to the encounter and practice setting.

Subjective: Record the patient’s concerns, symptoms, functioning and participation, goals, preferences, relevant history and context, and response or adverse effects from previous care.

Objective: Record relevant examination findings, outcome measures, diagnostic test results when available, and clinically important changes.

Assessment: Record the clinical interpretation of findings, working diagnosis or clinical profile, differential and safety considerations, relevant risk factors or modifiers, and the patient’s progress or response.

Plan: Record care provided or proposed, education and self-management, consent and patient decisions, changes to the plan, agreed outcomes and reassessment point, referrals or co-management, follow-up, and discharge planning.

Document at the time of the encounter or as soon as practicable. Corrections and additions should preserve the integrity of the record. Clear records support patient safety, shared decision-making, communication, continuity, and accountability.

2. Informed Consent
  • Definition: A continuing process in which a capable patient, or an authorized substitute decision-maker when required, voluntarily agrees to a proposed examination or intervention after receiving and understanding the information needed to make an informed choice.
  • Key Aspects:
    • Prior to interaction: Obtain consent before beginning an examination, procedure, or treatment, except where applicable law permits otherwise. Explain what is proposed and why. Revisit consent when the plan or material information changes.
    • Voluntarily and specific: must be voluntary and specific to the proposed care. Consider the patient’s capacity for the decision at the time it is required and follow applicable requirements for substitute decision-making when the patient lacks capacity. The patient may ask questions, refuse, place limits on, or withdraw consent.
    • Transparent process: Use honest, plain, and accessible communication. Offer interpretation or other communication support when needed and consider language, culture, health literacy, disability, and prior trauma. Written or digital information may support but does not replace discussion.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain relevant findings, the clinical impression or working diagnosis, important uncertainty, and the expected course in understandable language.
      • Treatment plan: Discuss the nature and purpose of proposed care, expected benefits, material risks and side effects, burdens, reasonable alternatives, the option of no intervention, and the likely consequences of accepting or declining.
      • Questions: Invite questions, explore goals and preferences, allow appropriate time for a decision, and confirm understanding, for example using teach-back.
    • Documentation: Record the consent discussion and decision, including material information provided, questions, capacity or substitute decision-maker where relevant, consent, refusal, limits or withdrawal, and any need to revisit consent. Follow documentation requirements applicable to the jurisdiction and practice setting.
3. Health History
  • Apply cultural awareness and trauma-informed care principles.
  • Sociodemographic information: Age, gender, sex, race/ethnicity, living situation (alone vs supported), access to transportation and rehabilitation services. 
  • Primary post-operative concerns: 
  • Location: Operated knee (anterior knee pain most common; may include peri-patellar or posterior knee discomfort).
  • Onset: Post-surgical; note timing relative to surgery and rehabilitation phase.
  • Duration: Time since surgery and evolution of symptoms.
  • Radiation: Localized vs diffuse knee pain.
  • Frequency, intensity, and character: Pain (rest vs activity-related), stiffness, swelling, perceived instability, or weakness.
  • Aggravating/relieving factors: Walking, stairs, sit-to-stand, prolonged standing or sitting, kneeling, sleep positioning, exercise load.
  • Associated symptoms: Swelling, reduced range of motion, gait difficulty, sleep disturbance, fatigue, reduced confidence with movement.
  • Body systems review:
    Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal (including contralateral knee, hip, and spine), bone density, respiratory, skin/wound status, mental health.
  • Health, lifestyle, and history:
  • Past medical conditions (e.g., osteoarthritis, diabetes, cardiovascular disease, obesity, inflammatory disease).
  • Medications (including anticoagulants, analgesics, opioids, corticosteroids where relevant), supplements.
  • Prior surgeries (including contralateral knee replacement), injuries, or hospitalizations.
  • Physical activity level pre- and post-operatively, participation in prehabilitation if applicable.
  • Sleep habits, smoking, alcohol or substance use, family support, caregiver responsibilities.
  • Work or daily environment (stairs, prolonged standing or sitting, lifting demands).
  • Social determinants of health: Employment status, caregiving responsibilities, education, nutrition, housing, financial constraints, access to rehabilitation services (in-person or virtual), ability to adhere to home programs.
  • Previous treatments and responses: Document inpatient, outpatient, or home-based rehabilitation received, adherence, perceived effectiveness, and any adverse responses.
  • Beliefs and expectations: Assess patient understanding of recovery timelines, expectations regarding pain, stiffness, and function, and personal goals for rehabilitation.
  • Flag considerations: Identify red, orange, and yellow flags influencing rehabilitation progression or requiring referral.

​​Outcomes Assessments: Prioritize approaches that align with the patient’s specific goals and stage of recovery.

  • Pain: Use pain scales (e.g., NRS) and diagrams.
  • Function and Participation: Evaluate impact on daily activities (KOOS, LEFS, PSFS, WHODAS).
  • Recovery: Use Self-rated recovery scales.
  • Quality of Life: Assess using tools such as SF-12.
  • Work/school Status: Monitor participation and return to activities.
  • Sleep quality: Assess using tools such as PSQI.
  • Individual Goals: Set SMART goal setting (Specific, Measurable, Achievable, Relevant, Timely).
  • Patient Feedback: Gatherand integrate patient experience and satisfaction.
4. Red Flags : Differential Diagnosis Requiring Medical Attention

ACTION: Refer immediately to emergency care:

  • Suspected Post-operative Complications
    • Infection: Increasing pain, warmth, redness, swelling, wound drainage, fever/chills, malaise, or delayed wound healing.
    • Venous thromboembolism (DVT/PE): Calf or thigh pain, swelling, erythema, tenderness; sudden shortness of breath, chest pain, hemoptysis, or unexplained tachycardia.
    • Neurovascular compromise: New or progressive numbness, weakness, loss of distal pulses, or severe disproportionate pain.
  • Mechanical or Surgical Concerns
    • Acute loss of function or sudden instability: New inability to bear weight, sudden giving way, or suspected prosthetic dislocation or periprosthetic fracture (e.g., following a fall or trauma).
    • Severe or escalating pain not consistent with expected post-operative course, especially if unresponsive to appropriate load modification and analgesia.
  • Systemic or Medical Concerns
    • Cardiopulmonary symptoms: Chest pain, syncope, new arrhythmia, or unexplained shortness of breath.
    • Adverse medication effects: Signs of bleeding (particularly in patients on anticoagulation), confusion, or severe gastrointestinal symptoms.

ACTION: Refer to appropriate medical provider:

  • Persistent or worsening swelling, stiffness, or pain beyond expected recovery timelines despite appropriate rehabilitation.
  • Marked or progressive loss of range of motion (e.g., suspected arthrofibrosis) that limits functional progression.
  • Wound concerns (e.g., delayed healing, increasing drainage) without systemic signs of infection.
  • Psychological distress or severe fear of movement that significantly limits rehabilitation engagement and recovery.

Red flags should be interpreted in the context of time since surgery, comorbidities, and the individual’s expected recovery trajectory. Early identification and referral are essential to optimize outcomes following knee replacement.

5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

  • Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
  • Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
  • Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

  • Suicide or self-harm thoughts: thoughts without immediate danger.
  • Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
  • Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

  • Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
  • Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
  • Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
  • Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

6. Yellow Flags: Factors that May Affect Recovery or Participation

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

  • Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
  • Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
  • Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
  • Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
  • Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
  • Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

  • Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
  • Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
  • Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
  • Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
  • Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.
7. Physical Examination Following Knee Replacement

The physical examination following knee replacement should focus on monitoring recovery, identifying impairments that may limit function, and detecting deviations from expected post-operative trajectories. Findings should be interpreted in the context of time since surgery and individual recovery goals.

  • Observation and general assessment:
    Posture, limb alignment, swelling/effusion, skin integrity, bruising, and surgical scar/wound status (healing, redness, drainage). Observe use of assistive devices and overall movement confidence.
  • Gait assessment:
    Walking pattern with and without assistive devices; step length, cadence, symmetry, knee extension in stance, loading response, and compensatory strategies (e.g., trunk lean, reduced weight-bearing).
  • Range of motion (ROM):
    • Active and passive knee flexion and extension
    • Compare with expected post-operative milestones rather than pre-injury norms
    • Assess end-feel, pain response, and symmetry with the contralateral side
    • Note extension lag or flexion limitations that may affect function
  • Strength assessment:
    • Quadriceps activation and strength (including extensor lag)
    • Hip and ankle strength as contributors to gait and functional tasks
    • Use functional or resisted testing appropriate to recovery stage
  • Swelling and pain response:
    Assess effusion, warmth, tenderness, and pain behaviour during movement and loading.
  • Functional testing:
    Based on recovery stage and tolerance, assess tasks such as:
    • Sit-to-stand and chair transfers
    • Stair negotiation
    • Balance and single-limb loading (as appropriate)
    • Functional reach or step tasks
  • Neurologic and vascular screening:
    Sensation, motor function, distal pulses, and signs of neurovascular compromise when indicated.
  • Adjacent regions:
    Screen the hip, ankle, and lumbar spine for mobility or strength deficits that may influence knee loading and recovery.

The physical examination should be repeated and adapted over time to monitor progress, guide progression of rehabilitation, and identify the need for modification or referral.

8. Clinical Presentations Following Knee Replacement

Clinical presentation following knee replacement reflects a predictable recovery trajectory, with expected variation based on individual factors, surgical course, comorbidities, and rehabilitation access. Presentations should be interpreted relative to time since surgery rather than as static.

Typical Early Post-operative Presentation (Weeks 0–6)

  • Pain and swelling around the operated knee
  • Reduced active and passive range of motion, particularly knee extension and flexion
  • Quadriceps inhibition and weakness, often with extensor lag
  • Gait impairment requiring assistive devices
  • Difficulty with functional tasks such as sit-to-stand, walking, and stairs
  • Sleep disturbance and fatigue

Intermediate Recovery Presentation (Weeks 6–12)

  • Gradual reduction in pain and swelling
  • Improving knee range of motion and strength
  • Transition away from assistive devices as gait symmetry improves
  • Ongoing limitations with stairs, prolonged walking, kneeling, or uneven surfaces
  • Increasing participation in daily activities, with residual stiffness or soreness after loading

Later Recovery Presentation (Beyond 3 Months)

  • Some individuals may experience ongoing pain or functional limitations despite technically successful surgery
  • Continued gains in strength, endurance, and functional capacity
  • Residual stiffness, discomfort, or swelling with higher-level activities may persist
  • Variable recovery of confidence with movement and participation

Atypical or Delayed Recovery Patterns

  • Persistent pain, swelling, or stiffness that limits functional progression
  • Failure to achieve expected improvements in range of motion or strength
  • Ongoing gait deviations or reliance on assistive devices beyond expected timelines
  • Psychological factors (e.g., fear of movement, low recovery expectations) contributing to reduced rehabilitation engagement

Clinical presentations following knee replacement often overlap and evolve over time. Rehabilitation should be responsive to the individual’s presentation, with regular reassessment to guide progression, identify barriers to recovery, and determine whether further evaluation or referral is warranted.

9. Rehabilitation Following Knee Replacement

Approach to Treatment

Rehabilitation is a primary determinant of outcomes following knee replacement and should be initiated early, progressed systematically, and sustained over time. Management should be patient-centred, function-focused, and goal-oriented, accounting for surgical course, comorbidities, recovery phase, and contextual factors.

The components below represent core domains of post–knee replacement rehabilitation consistently supported by clinical practice guidelines and systematic reviews. Not all elements are required for every individual or at every stage. Clinicians should apply professional judgment when selecting, sequencing, and progressing care.

This pathway is not prescriptive and does not specify exercise dosage or setting. Care may be delivered through inpatient, outpatient, home-based, or hybrid models depending on individual needs and access.

Education and Self-Management

Education is foundational and should be initiated early and reinforced throughout recovery.

Key elements include:

  • Clear explanation of expected recovery timelines, normal post-operative symptoms (pain, swelling, stiffness), and variability in recovery
  • Reassurance regarding the safety of movement and loading
  • Guidance on activity pacing, swelling management, and symptom monitoring
  • Promotion of self-management behaviours (physical activity, sleep hygiene, nutrition, stress management)
  • Support for adherence to home programs and long-term physical activity

Exercise Therapy

Exercise therapy is the cornerstone of post–knee replacement rehabilitation.

Programs should be:

  • Progressive and individualized
  • Focused on restoring:
    • Knee range of motion (particularly extension)
    • Quadriceps strength and activation
    • Hip and lower-limb strength
    • Gait quality and functional movement patterns
    • Endurance and tolerance for daily activities
  • Integrated with functional task training (e.g., transfers, stairs, walking)

No single exercise program or delivery model has been shown to be superior. Programs should align with patient goals, recovery stage, and participation demands.

Manual Therapy

Manual therapy may be used as an adjunct to support pain modulation, movement confidence, and participation in active rehabilitation.

Manual therapy should:

  • Be used selectively and short term
  • Support, not replace, active exercise and functional training
  • Not be used as a stand-alone intervention

Functional and Gait Retraining

  • Progressive gait retraining to restore symmetry, confidence, and efficiency
  • Gradual progression of functional tasks (stairs, uneven surfaces, prolonged walking)
  • Balance and proprioceptive training as appropriate to recovery stage

Medications and Symptom Management (Medical Provider)

  • Analgesics and NSAIDs may be used short term as part of multimodal pain management, guided by a medical provider
  • Long-term opioid use is not recommended
  • Ongoing pain or swelling that limits rehabilitation should prompt reassessment rather than escalation based on imaging alone

Escalation and Referral

Consider referral for further assessment when there is:

  • Failure to progress despite an adequate trial of rehabilitation
  • Persistent or worsening pain, stiffness, or functional limitation
  • Suspected complications (see Red Flags)
  • Significant psychosocial barriers affecting recovery

Shared decision-making should guide any escalation beyond conservative rehabilitation.

(Cochrane 2018; Jette 2020; Healthcare Excellence Canada; NICE 2020; Rehabilitation Care Alliance)

10. Risk and Prognostic Factors and Prognosis

Risk Factors

Recovery after knee replacement is influenced by a combination of clinical, functional, and contextual factors. Common risk factors for slower recovery or persistent symptoms include:

  • Pre-operative status: Higher pain and disability before surgery, limited pre-operative strength or mobility, and lower physical conditioning.
  • Comorbidities: Obesity, diabetes, cardiovascular disease, inflammatory conditions, and chronic pain conditions.
  • Surgical and early post-operative factors: Post-operative complications, prolonged immobilization, or delayed initiation of rehabilitation.
  • Movement and functional factors: Persistent quadriceps inhibition, limited knee extension, gait asymmetry, or reduced tolerance to progressive loading.
  • Psychosocial factors: Anxiety, depression, fear of movement, pain catastrophizing, or low expectations of recovery.
  • Contextual and social factors: Limited social support, barriers to accessing rehabilitation, difficulty adhering to home programs, or competing caregiving or work demands.

Prognostic Factors

Factors associated with better recovery trajectories include:

  • Early engagement in structured, progressive rehabilitation
  • Gradual improvement in knee extension, quadriceps strength, and functional tasks
  • Ability to modify activities and pace loading during recovery
  • Positive recovery expectations and sustained engagement in rehabilitation

Imaging findings or implant characteristics alone are not reliable predictors of functional outcome.

Prognosis

The prognosis following knee replacement is generally favourable, with most individuals achieving meaningful improvements in pain, function, and quality of life within the first year after surgery.

  • Functional gains often continue for 6–12 months, with variability in recovery timelines.
  • Some individuals experience persistent pain, stiffness, or functional limitations despite technically successful surgery, highlighting the importance of rehabilitation quality and continuity.
  • Failure to progress after an appropriate trial of conservative rehabilitation should prompt reassessment and shared decision-making, rather than automatic escalation to further procedures.

Overall, outcomes are optimized when rehabilitation is timely, progressive, patient-centred, and responsive to individual needs and context.

11. Ongoing Follow-up

Ongoing follow-up is a shared review of whether the plan remains safe, useful, acceptable and aligned with the patient’s goals. The timing of review should reflect symptoms, risk, the care being tried, goals and access rather than a fixed visit schedule.

  • Review symptoms and safety: ask what has changed in symptoms, functioning and daily activities; review adverse effects; and check for new or worsening Red Flags and relevant Orange or Yellow Flag concerns. Arrange earlier or urgent assessment when the findings require it.
  • Review outcomes: repeat the small set chosen at baseline and use the same measures when possible. These may include the Patient-Specific Functional Scale, WHODAS 2.0, quality of life using the patient’s own rating or a measure such as WHOQOL-BREF, symptom impact, participation and the patient’s own assessment of change. Interpret measures with the patient and alongside what has changed in daily life rather than relying on a score alone.
  • Review goals, preferences and consent: ask whether care remains acceptable, feasible and worthwhile; revisit goals and priorities; and confirm consent when the plan or circumstances change.
  • Adapt care: continue what is useful and acceptable, and change, pause or stop what is not. If progress is not sufficient from the patient’s perspective, review the clinical impression, the fit and amount of care, barriers to participation, other health or social factors and whether other expertise is needed.
  • Support self-management and participation: review the strategies the patient is using, including physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Ask what is helping and which barriers can be addressed.
  • Referral and co-management: arrange emergency assessment for Red Flags requiring urgent care. Consider referral or co-management when findings or needs are beyond the clinician’s role, the patient’s condition is worsening, progress remains insufficient after the plan has been reviewed, or the patient requests another opinion.
  • Plan the next step: agree whether to continue, change the interval between visits, move toward more self-directed care, or apply the Criteria for Discharge section.
12. Criteria for Discharge

Discharge is a shared decision about ending or transferring a course of care. It does not require complete symptom resolution, a normal outcome score or a fixed number of visits.

  • When discharge may be appropriate: consider discharge when the patient’s goals have been met to a degree they consider satisfactory; the patient feels able to manage with less or no clinician involvement; the patient chooses to end care; continued care is not providing enough benefit to justify its burden, cost or time; or care is being transferred to another provider.
  • Reassess before discharge: review symptoms, functioning, participation, selected outcomes, goals, adverse effects, confidence and preferences. Check for new or worsening Red Flags and any Orange or Yellow Flag concerns that still require action. If the condition is worsening or a safety concern remains, arrange the required assessment or referral rather than routine discharge.
  • When progress has slowed: review the clinical impression, response to care, goals, barriers and access, other health or social factors, and other reasonable options before deciding with the patient whether to continue, change or end care.
  • Plan after discharge: agree on self-management, physical activity or exercise, symptom management, pacing and participation in work, school, caregiving, recreation or community life. Explain which changes should prompt earlier or urgent assessment and when and where to seek care.
  • Future access to care: explain how the patient can return if symptoms recur, functioning declines, or goals or demands change. Any planned future review or supportive care should have an agreed purpose, expected benefit and review point.
  • Referral or transfer: explain the reason, share a relevant summary with the patient’s consent, and clarify who will address outstanding concerns when possible. Avoid an unintended gap in care when safety or ongoing needs remain.
  • If the patient ends care or does not return: respect the patient’s right to stop. Record what is known and unknown about the outcome, advice or referral offered, attempts to communicate when clinically warranted, and any unresolved safety concern. Follow applicable record keeping and communication requirements.
  • Documentation: record the reason care ended, the patient’s status and selected outcomes, goals and preferences, unresolved concerns, advice and self-management plan, referral or transfer details, and how to seek care again if needed.

References