Pre and Post-Operative Physiotherapy in Knee Replacement Surgeries

Knee Arthroplasty from a Physios Perspective

¢  Elderly patient (Maybe retired and financially dependent)

¢  Sedentary lifestyle (Maybe overweight/ obese)

¢  Degenerative changes

¢  Functional Goal setting: Making the patient functionally independent to be able to perform Basic ADL’s (and Instrumental ADL’s) with or without assistive device.

            http://physiotherapy-today.blogspot.in/2014/06/knee-pain-and-osteoarthritis.html

                http://physiotherapy-today.blogspot.in/2014/06/old-age-boon-or-bane.html

Considerations for Rehab 

¢  Age of the patient (Young patient???)

¢  Pre op signs & symptoms

¢  Pre-Injury Status – Cardio respiratory status

¢  Functional Requirement of Individual (Activity Level)

-          Sedentary Lifestyle

-          Active Lifestyle 

¢  Associated Factors

-          Type of disease

-          Severity of involvement

-          Deformity

-          Associated injuries

Knee Arthroplasty

Indications for Surgery:

-          Severe joint pain

-          Extensive destruction of Articular cartilage

-          Deformity of the knee

-          Gross instability

-          Limited ROM

-          Non operative/ Surgical management failure

-          DECISION TO ACCEPT THE CHANGED LIFESTYLE

Arthroplasty – Physiotherapists Consideration

¢  No. of Compartments replaced:

-          Uni, Bi, Tri

¢  Implant Design:

¢  Unconstrained, Semi constrained, Fully Constrained

¢  Mobile bearing/ fixed bearing

¢  Surgical Approach:

¢  Standard or Minimally invasive

¢  Quads splitting or Quads sparing

¢  Implant Fixation:

¢  Cemented, Un-cemented, Hybrid

Pre-Operative Physiotherapy

¢  Pre-operative physiotherapy-based interventions can improve sit-to-stand, stair climbing/ descending ability and standing balance post-TKA but do not have a significant effect on self-reported function, pain levels, range of motion or length of stay in the short-term

            Lucy Simmons, Toby Smith Phys Ther Rev, 2013

¢  Evidence suggests that preconditioning has a modest impact in improving post-operative outcomes

            Gill et al, Arch Phys Med, 2013

                Rikke Helene Moe, Hanne Dagfinrud. Journal of Physiotherapy 2014

¢  Pre op physiotherapy may accelerate healing and reduce medical cost associated with surgery

            Jordan RW et al, Physiotherapy, 2014

¢  Pre op physiotherapy including pain management, NMES, muscle strengthening programs including PRE.

¢  NMES given pre op for patients undergoing TKA has shown to accelerate post op rehab

            Ibrahim et al, BMC Medicine. 2013

Post-Operative Management

1. Phase I or Maximum protection phase  – Weeks 1 – 4
2. Phase II or Moderate protection phase – Weeks 4 – 8
3. Phase III or Minimum Protection phase – Weeks 8 & beyond

Maximum protection phase: weeks 1 – 4:

TREATMENT GOALS:

¢  Control post op swelling

¢  Minimize pain

¢  ROM 0 – 90°

¢  Muscle strength: Grade 3/5 – 4/5

¢  Ambulation (with or without assistive device/ supervision)

-          Chester Knee Clinic & Cartilage Repair Centre Nuffield Health, The Grosvenor Hospital Chester

-          Brigham & Women’s Hospital, Massachusetts, Dept of Rehab Services

-          Osteoarthritis Service Integration System (OASIS): www.vch.ca/oasis

-          Physiotherapy Association of British Columbia (PABC):

-          NHS Foundation Trust

Intervention

¢  Pain Modulation

¢  Compression

¢  Prevent vascular & Pulmonary complications

¢  Prevent reflex inhibition/ loss of strength of knee & hip musculature

¢  Active assisted/ Active ROM exercises

¢  Muscle setting excs – Quads, Hams & adductors

¢  Patellar mobilizations

¢  Flexibility – Hams, TA, ITB

¢  Gait

            Cameron H 2003, Ecker ML 1989, Enloe J 1996, Jaramillo J 1993, Scolco T 1999

Issues during Early Post- Operative Phase/ Phase I/ Maximum Protection Phase

Pain and Inflammation:

¢  Adequate management of pain and inflammation essential to meet the goals of rehab

            D’amoto and Bach 2003

¢  Extensive use of Cryotherapy and Compression Dressings

¢  Reducing Inflammation – promotes neuromuscular control, activation of muscles which is essential to maintain normal joint movement

¢  Pain management using analgesics including narcotics – help patient to tolerate pain associated with exercise

            Cascio et al 2004

¢  TENS can be used as multimodal analgesia for pain relief and gaining early function of the knee

            Zhang et al 2014

¢  A systematic review suggests, amongst various therapeutic modalities, TENS demonstrated the strongest and most consistent effects in increasing voluntary quadriceps activation

            Matthew S et al. Journal of Athletic Training: 2014

CRYOTHERAPY

¢  Applying both low-intensity pulsed ultrasound and cryotherapy can relieve inflammation and enhance joint function in patients who undergo total knee replacement.

Kang et al, J Phys Ther Sci 2014

¢  Cryotherapy is useful to quadriceps activation in patients with arthrogenic inhibition

            Ewell, Melvin et al PM&R, 2014

            

¢  Immobilisation & Early mobilisation:

Use of CPM: No longer recommended after primary TKR or used as an adjunct (not replacement) post operatively

¢  Does not provide any additional benefit over conventional interventions

            Davis DM, Jones CA 2001, Denis M 2006, MacDonald SJ 2000, Boese 2014, Herbold JA et al 2014

¢  Weight bearing:

            Type of prosthesis, fixation, age of pt., bone quality, use of knee immobilizers.

            Rand JA  1996, Pagnano 2003, Scott RD 2006

¢  Use of assistive device:

            Adequate strength of Quadriceps & hip muscles to control operated lower limb.

            Cameron H 2003, Pagnano 2003, Martin SD 1998

¢  The high correlation between quadriceps strength and functional performance suggests that improved postoperative quadriceps strengthening could be important to enhance the potential benefits of TKA. 

            Mizner et al, J Orthop Sports Phys Ther 2005

¢  Hip abductor strength highly correlates with improved physical performance after unilateral knee Arthroplasty

            Alnahdi AH, Zeni JA, Snyder-Mackler L. Phys Ther. 2014

¢  NMES performed regularly during the immediate post-operative phase helped to attenuate dramatic losses in quadriceps strength following TKA, thereby resulting in overall improvements in strength and function.

            Kittelson AJ, Stackhouse SK, Stevens-Lapsley JE Eur J Phys Rehabil Med 2013

Moderate Protection Phase Weeks 4 – 8

TREATMENT GOALS:

¢  Reduce Swelling

¢  ROM 0 – 110° (or more depending on implant type)

¢  Full Weight bearing

¢  Strength 4/5 – 5/5

¢  Unrestricted ADL functioning of patients

¢  Home exercises. program

Intervention

¢  Patellar mobilizations

¢  Stretching programs

¢  Closed chain strengthening (if permitted)

¢  Open chain PRE exercises & multiple angle isometrics

¢  Proprioceptive training

¢  Stabilization exercises, setting exercises & co contractions

¢  Protected aerobic exercises – walking, cycling or swimming (if permitted)

¢  Gait training

Proprioceptive training

¢  Proprioceptive and sensorimotor system deficits observed post Arthroplasty can contribute to progression of degeneration and increased risk of falls

            Slupik A, Ortop Traumatol Rehabil, 2013

¢  Closed chain exercises can be used for enhancement of proprioception post TKR, however not beneficial as an early intervention

            Karandikar G.S, Bedekar NS, Sancheti PK, Ind J Phys Occ Ther, 2014

¢  Proprioception training can effectively improve dynamic and static balance knee, knee ROM independent walking ability of patients after TKR

            WU Wan-xia et al, Ortho J China, 2013

¢  Additional balance training has a beneficial effect on functional recovery and mobility in patients with OA knees  after TKR

            Chun-De Liao, Clin Rehabil August 2013

Gait training

¢  Gait training is very important

¢  Gender wise variations may be observed and should be considered

            Astephen Wilson et al J Arthroplasty, 2014

¢  Earlier mobilization and ambulation is associated with shorter length of stay, lower hospitalisation costs and improved knee function post TKR

            Pua YH, Am J Phys Med Rehabil, 2014

Yoga after Arthroplasty

¢  Yoga as an adjunct to conventional physiotherapy helps in pain relief and early recovery of function and knee ROM

¢   Yoga asanas like-

-          Shavasana,

-          Tadasana,

-          Paschimottanasana,

-          Pavanamuktanasana,

-          Baddha-konasana,

¢  Post stitch removal- Ardha shalabasana.

¢  At six weeks- Virbhadrasana, Utkatasana

            Bedekar N, Sancheti K, Sancheti P. Int J Yoga 2012

Minimum Protection Phase – weeks 8 & beyond:

TREATMENT GOALS:

¢  Adherence to exercise program: maintaining joint flexibility, balance training

¢  Improve cardio pulmonary endurance/ aerobic fitness

¢  Joint protection

Intervention:

¢  Continuance of exercises as in moderate protection phase

¢  Advancement of exercises as appropriate & as pt’s needs.

¢  Exercises specific to functional tasks/ activities.

¢  Proprioceptive training for strength, balance & endurance activities.

¢  Community participation for selective recreational activities.

¢  Improvement of patients’ Quality of life & physical functioning.

Current Trends in Rehabilitation

¢  Shift towards individually tailored/ modified programs depending on functional requirement of the individual

¢  Functional training programs – exercises similar to ADL’s of the individual

¢  Limited Use of CPM machines

¢  Cryotherapy pre-op/ post-op beneficial to control pain and swelling

¢  Functional Testing to assess joint stability

¢  Emphasis on Proprioceptive Training

¢  Patient Perceived joint stability most important criteria for Prognosis

¢  Time not a major factor in determining treatment progression

¢  ROM, muscle strength and patient perceived joint stability most important criteria for exercise progression

¢  Delayed Surgery – faster strength recovery

            Wasilewski  et al 1993 , Shelbourne and Foulk 1995

Things to remember!

¢  No fixed Protocol for rehab

¢  Modify Exercises by regular patient evaluation

¢  Task Specific and Functional Exercises more effective

¢  Rehabilitation greatly influenced by level of motivation of the patient and compliance to the exercise program