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Rehab post Total knee manipulation

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Rehab post Total knee manipulation - July 8, 2007 9:21:27 AM   
jma

 

Posts: 2414
Joined: August 24, 2000
From: NY
Status: offline 		Hello,
Would like to know how one deals with a post TKR manipulation that isn't responding to ROM exercises. How common is this? And what are your strategies for dealing with it. Thanks in advance.
Post #: 1
RE: Rehab post Total knee manipulation - July 8, 2007 12:54:34 PM   
bonmar

 

Posts: 137
Joined: August 15, 2000
From: Boston, MA
Status: offline 		I usually have the patient work on independent ROM exercises first during a treatment session such as light loaded leg press and the stationary bike and then I work manually. I find that if the patient works ROM themselves with a specific goal in mind (i.e. "I want you to keep working this leg press until you get to 75 degrees")  they respond better than me trying to range the knee. Some people work better when they are controlling their pain and motion. I also stess proper gait in clinic since every step they are taking is reinforcing normal knee motion.

Closed chain exercise also works well i.e. supine bridging...when they are in the bridge position, I slide their heel closer to their buttocks, hold it there, and then have them lower easily....or standing small squats (with a chair behind them).

(in reply to jma)
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RE: Rehab post Total knee manipulation - July 8, 2007 1:19:06 PM   
jma

 

Posts: 2414
Joined: August 24, 2000
From: NY
Status: offline 		Hmm. Now to get the patient with enough knee flexion to even try the leg press. Thanks for the tips.

(in reply to bonmar)
Post #: 3
RE: Rehab post Total knee manipulation - July 8, 2007 2:00:50 PM   
bonmar

 

Posts: 137
Joined: August 15, 2000
From: Boston, MA
Status: offline 		I know, I know...it sounds daunting. Have the patient put the good leg up on the leg press, extend, and then place the injured leg up. Have the patient control the amount of knee flexion from that point. Again, use light weight...the amount that the good leg can handle on its own.

(in reply to jma)
Post #: 4
RE: Rehab post Total knee manipulation - July 8, 2007 9:00:12 PM   
KAK

 

Posts: 200
Joined: December 1, 2004
Status: offline 		What are the ROM measurements now and how long ago was the manipulation?  Scarring can be nasty and painful for these folks.
 
I like to find out how much range the doctor got during the manipulation.  I share this with the patient to let them know it is possible for their knee to bend that far.  I explain that we have a small window of opportunity to keep this range. I also do a lot of education regarding the time the tissue needs to be at end range to allow for adaptation of the soft tissue (and their nervous system).  I think the reducing fear and having the patient on board is huge.
 
If pain is the issue, I encourage patients to talk to their physician to get on meds that sufficiently control the pain to allow them to work sufficiently. 
 
I find that these patients respond to gentle prolonged stretched (self stretching seems to work better). I tend to spend the whole session working on range initially.  If flexion is the main limitation I’ll spend the whole session doing various flexion activities- hitting it from all different angles. If flexion and extension are limited, I focus on one at a time in the clinic- for example all flexion exercises followed by all extension exercises. Patients seem to like sitting on the ball and rolling forward to get a flexion stretch.  Also, prone with a belt around their ankle- allowing them the control and holding a 30-60 second stretch seems to work well.  I ask them to hit it hard at home- at least 3 sessions per day- all stretching exercises initially. I find that a supine heel slide with a sheet wrapped around the ankle works well for home. I don’t worry about strength-strengthening can come later as they have enough work cut out for them.
 
I ask them to sit at home with the knee bent at or near end range as much as possible.  I encourage them to work on sit-stand with the knee bent as much as possible for functional reinforcement.
 
I avoid being too aggressive as I find that most patients who have scarring issues (at least the ones who try), do so because of excessive inflammation or bleeding to begin with.  Also, younger patients with a great blood supply tend to adhere quicker if they don’t get off to a good start.  Good luck!

(in reply to bonmar)
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RE: Rehab post Total knee manipulation - July 9, 2007 12:19:50 PM   
jma

 

Posts: 2414
Joined: August 24, 2000
From: NY
Status: offline 		The range post manip was about 115 degrees and came to therapy 2 days later and was down to 65 degrees. Pt has been given a CPM to use at home. Been trying all of the above. Yes, it is slow progress. Thanks for the info

(in reply to KAK)
Post #: 6
RE: Rehab post Total knee manipulation - July 9, 2007 8:25:37 PM   
KAK

 

Posts: 200
Joined: December 1, 2004
Status: offline 		Dang… that’s a huge change!  Must be very frustrating on your end…

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RE: Rehab post Total knee manipulation - July 9, 2007 8:41:42 PM   
jma

 

Posts: 2414
Joined: August 24, 2000
From: NY
Status: offline 		It is but the patient is determined not to go through another manipulation again.

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RE: Rehab post Total knee manipulation - July 17, 2007 10:57:02 AM   
USAPT

 

Posts: 278
Joined: January 14, 2004
Status: offline 		JMA,
I've had good results from a JAS or Dynaspint for the low load prolonged stretch instead of the CPM

-Jason   

(in reply to jma)
Post #: 9
RE: Rehab post Total knee manipulation - July 17, 2007 7:04:34 PM   
Chocco

 

Posts: 58
Joined: September 5, 2006
Status: offline 		With the right patient i have had some good success with the JAS. Dynasplints in my experience work but tend to have a lot more problems.
Swelling could be the cause of such a dramatic dropoff. Manipulations are pretty agressive and although the doctor is able to get a lot of motion during the manipulation if the patient is unable to control the edema they are going to loose a lot of mobility as that leg swells. Same thing to remember to remember with your therapy It's great to work that leg in the clinic agressively but if the patient is unable to control the edema from treatments when the go home the knee can swell and tighten up again. I have also had success with mulligan techniques for increasing knee flexon.

(in reply to USAPT)
Post #: 10
RE: Rehab post Total knee manipulation - July 17, 2007 8:26:17 PM   
jma

 

Posts: 2414
Joined: August 24, 2000
From: NY
Status: offline 		Thanks for the tips guys!

(in reply to Chocco)
Post #: 11
RE: Rehab post Total knee manipulation - July 18, 2007 12:08:08 AM   
alodato

 

Posts: 23
Joined: April 9, 2007
From: Woodinville, WA
Status: offline 		I have post-manip pts come in the afternoon they get their manipulation and make sure they can get to the ROM the Doc got in the OR.  Then they have to come back the following morning and again get the same ROM.  Then if that is achieved, its 3 x wk for 4 wks.

(in reply to jma)
Post #: 12
RE: Rehab post Total knee manipulation - July 18, 2007 1:18:19 PM   
jma

 

Posts: 2414
Joined: August 24, 2000
From: NY
Status: offline 		If the patient does not improve within 2 weeks, the surgeon mentioned going in a "clearing out" the fibrous tissue and not do another manipulation.

(in reply to alodato)
Post #: 13
RE: Rehab post Total knee manipulation - August 8, 2007 10:43:39 PM   
AdamP

 

Posts: 23
Joined: July 27, 2007
Status: offline 		With a change that large and no other information, I would be surprised if the pt is fully compliant or understands that they need to ush their pain threshold. I tend to be more aggressive post-manipulation and agree with the previous post to quickly achieve 115 degrees. I would think the 65 degrees is muscle guarding? I like to place them in a knee to chest position (if tolerated) to lessen the strength of a quad contraction to resist flexion then stretch every way I can think of until I find one they respond to (including contract relax).

(in reply to jma)
Post #: 14
RE: Rehab post Total knee manipulation - August 9, 2007 7:35:30 AM   
jma

 

Posts: 2414
Joined: August 24, 2000
From: NY
Status: offline 		The patient was very compliant but the knee wasn't. She will have the arthroscopic surgery and then see what becomes of it.

(in reply to AdamP)
Post #: 15
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