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.
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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
- Phase
I or Maximum protection phase –
Weeks 1 – 4
- Phase
II or Moderate protection phase – Weeks 4 – 8
- 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
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