|
|
Restoring postoperative knee ROM
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Restoring postoperative knee ROM - July 11, 2008 10:54:00 PM
|
|
|
TexasOrtho
Posts: 560
Joined: December 22, 2007
Status: offline
|
Hey folks. I've got an idea. Why don't we try to develop a consensus or position statement on postoperative restoration of motion. I've seen this take place on other forums where great minds (and me) get together and outline guidelines or opinions on various clinical issues.
What got me thinking was my strategy for improving extension and flexion at various stages of postoperative recovery. I don't like to admit it, but I still resort to static positioning for 3-5 minutes in supine or prone. Basically I just run with my gut and it often leads to success. I've often wondered if there is a better (and more gentle) way of restoring motion following surgery? So what is your approach during the acute and later stages of recovery? Continuous active/passive motion in mid range
Static passive holding at end-ranges? Something else? Let's do something with this.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 11, 2008 11:12:25 PM
|
|
|
cclem2000
Posts: 21
Joined: August 7, 2006
Status: offline
|
I like to encourage frequent range of motion to end range without increasing or re-triggering the inflammatory response. I dont usually have to "kill" these patients if they can be compliant with frequent (4-5 x/day) end range stretching when away from PT
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 12, 2008 9:27:30 AM
|
|
|
mwells144
Posts: 7
Joined: July 10, 2005
Status: offline
|
Lets assume it's a TKA.....I try to keep it simple and this works 90% of the time.
Pt comes in and gets 15 min heat to hamstrings in ext stretch with 3-5#s on femur.
2)seated HS stretch 3)extension mobs to femur/patella mobs (if indicated) 4)quad sets with Russian stim to quads 5)standing calf stretches/ TKE 6)step ups with focus on achieving full ext 7)prone HS stretch....then I focus on flexion (always tough to transition from extension to flexion initially)
1)heel slides with belt 2)wall slides 3) seated PROM/stretching with inferion gliding of tibia(traction pull) 4) prone or off edge of bed hip flexor/quad stretch 5) semi-recumbant bike 6) total gym squats
If a patient is compliant then this seems to be the appropriate stage I ROM program I will use before functional retraining. You can usually tell in 4-5 visits who is going to struggle with ROM. Then postion changes, IFC during stretching, *LESS* hands on stretching (as these pts typically muscle guard) works well. I have started making home dynasplint-like contraptions with theraband that gives a nice static stretch if necc.
Once every 6 months you get a pt that you can tell immediately that a larger then desired knee was put in...you are screwed when that happens....hard to tell the patient that the surgeon may have errorred
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 12, 2008 11:32:52 PM
|
|
|
annpsu25
Posts: 80
Joined: March 8, 2008
From: PA
Status: offline
|
I love this post for a few reasons:
I just finished an 8 week clinical round at an outpatient ortho clinic (private practice). The physician is well known around the area for his TKR (http://orthopedics.about.com/od/hipkneereplacement/a/rotating.htm). This TKR is quad sparing NOT minimally invasive. Every patient I treated from beginning stages to end stages (or close to) had amazing function with their new knee. We told the patients that the first 4 weeks are the most painful, and after those first 4 weeks the pain level should start to decrease. Patients are put on coumadin for 6 weeks, wear tedhose for 6 and most are put into an immobilizer if the ligaments are cut during surgery due to varus or valgus at the knee.
Protocol: QS with russian to VMO and rectus x 10' with heat, SAQ's with russion x 10' -increase wt as pt. progresses, SLR, supine and seated heel slides, and LAQ's during the first 1 or 2 treatments. Then the stationary bike is added, TKE (if needed), seated knee curls with t-band -> knee curl machine, leg press, treadmill, mini sqauts, step ups, at the 6 week mark the BTE machine to test quad and ham strength. At the end of each session ROM to get knee ext and flex measurements. Trying to get 5 degrees of knee bend each session. If after the first week or two there is negative ext, prone hangs x 5 min, along with prone knee curls- active and active assist. Ice afterwards. The clinics goal is to get 130 degrees of flexion. Pt's are usually weened from a walker to a cane by 4 weeks and have no assitive device after depending on each individuals needs.
I started my inpatient round this week, and filled in the outpatient for the hospital. A knee patient 4 weeks out came walking with a walker. This pt presented with trendelburg gait. After treatment-totally different might i add- i measured his knee bend (gravity assist). This man had 100 degrees. I was disappointed and wanted to so much to stay throughout the rest of his therapy. I had him walk around the clinic and constantly had to give verbal cues for him to bend his knee when he walks. He blames it on his "sore ankle" which he has had ever since surgery. Might i add that this man had home health for two weeks, stopped therapy (get this- b/c it wasnt needed!!) and is just now starting back.
This leads me to some of my own questions:
what does your clinic strive for, as far as ROM, etc?
Is there really an easier, less painful way of progressing the pt?
What should I expect to see from other clinics regarding their therapy treatments?
< Message edited by annpsu25 -- July 12, 2008 11:45:15 PM >
_____________________________
Allisha
LPTA
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 14, 2008 3:23:28 PM
|
|
|
buckeye
Posts: 175
Joined: May 24, 2007
Status: offline
|
Texas Ortho - nice idea. Can we develop a consensus for knee replacement that is driven by evidence, not just by clinical practice?
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 17, 2008 9:28:26 AM
|
|
|
bburas
Posts: 54
Joined: April 22, 2001
From: colorado springs, co, usa
Status: offline
|
Most of the ortho's I work with expect 120 degrees from a new knee. I rarely push them past that point but some have achieved more. I'll add some light contract relax activities for patients that really guard. I've found that releasing the hamstring (usually coupled with the C/R) will allow for impressive gains into extension.
Cclemm and I come from the same school of thought (or school), you don't have to "kill" these patients to achieve motion. I've found that if I'm too aggressive in the clinic the patient is too sore to perform his/her HEP and make slower improvement.
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 18, 2008 8:54:30 AM
|
|
|
Shill
Posts: 1097
Joined: February 13, 2003
From: Madison WI USA
Status: offline
|
No studies behind this description of my most recent method, but here it is. Using a supine leg press device (the shuttle 2000) as soon as I can get them on the device (usually week 2-4 post op, depending on when they get to me). They start by doing the typical heel slide as far as they feel they want to go, all the while with instruction on hurt versus harm, etc, etc. I let them decide how far to go, and verbally push them in minutae a bit further each time. Then, I have them to a leg press versus 20 lbs, or 40 lbs, something ridicuously easy, through full available ROM. They do a few reps, bend a bit more, and its a nice, patient controlled way to get ROM back without needing to force much of anything. It also helps them control TKE in a relatively functional movement against progressive resistance.
As an aside, you can expect up to 130 or more in most knees these days, so if you get 120, and ROM keeps coming easily, dont stop. Know what type of prosthesis they have, and the max flexion it is meant to go to.
I also teach them in the pre-operative visit to learn how to relax the quad and allow flexion of the knee completely passively in sitting, so that they shoot for this as a personal goal, to get 90 degrees prior to leaving the hospital. For inpatient PT's, I would recommend you use a truly passive seated flexion as the number one means of gaining relatively painless flexion. (again, no stats on this, but lets get real here, you wont find a study showing the best method for returning ROM after TKA, so either do one, or stop looking). It often hurts to come out of this, but it is transient pain that lasts a few seconds. They can handle this if they know it will be gone in a jiffy. Yes, I said jiffy.
There were times when I used to push with great force on these folks, but as I reflect on the results, the ROM achieved at each visit was relatively meaningless, as they could not even get close to this on their own, and the pain was the limiting factor. Sure they had a capsular end feel as well, but only when the pain abated could we make progress. Slow progress is what you will see once the capsule is allowed to stiffen, so get the ROM back in your 0-6 week window of opportunity, or its likely manipulation time.
So there you have my suggestions. I dont use heat, it takes too much time, will only use E stim if they cant get it without, (usually this relates exclusively to swelling inhibition of the quad, so I use edema reduction techniques first, then E stim, or not, as they often figure things out once the swelling is gone). I will use ice afterward, but often have the patient do this at home. Bike is great, prolonged gentle stretch is great, especially in those with flexion contractures.
One last side note. Those with correction of a significant varus or valgus tend to hurt more and take longer to make gains due to the adjustments needed in the medial and lateral knee from this rapid change. Valgus to straight seems to be worse, in my experience, and I relate this to the relatively sudden state of stretch on the peroneal nerve. I tell both of these populations to expect ankle pain as well afterward. Sometimes they get it, sometimes no, but if you prepare them for it, it is often so much better tolerated, as it is not a surprise.
OK, I am done. Have a nice weekend folks.
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 18, 2008 4:34:24 PM
|
|
|
buckeye
Posts: 175
Joined: May 24, 2007
Status: offline
|
Inpatient program - heel prop and heel slide.
Outpatient program - Total gym or shuttle, exercise bike, Nu-step, heel slide with strap for self assist, stair flexion (patient controls flexion), gravity assist flexion in supine, heel prop (often long sitting if there is quadriceps tightness), prone hang when incision looks great (may add ankle weights or elastic band to add stretch)
Stool scoots - forward and backward.
Stretch - hams, calves, and quads as indicated.
Rarely - Mulligan knee squeeze for flexion.
A few orthopedic surgeons near hear do not allow any passive over pressure - only gravity and active range.
No heat - the joint is already warm and inflamed from surgery.
Occasional e-stim if it must be used.
Cold packs after (in clinic or at home).
TexasOrtho - I think the static positioning mentioned by TexasOrtho is fine. Not sure why you were worried about mentioning this.
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 18, 2008 7:17:22 PM
|
|
|
TexasOrtho
Posts: 560
Joined: December 22, 2007
Status: offline
|
Hey folks. Just got back from a week down in Belize. Let me get my legs under me and we'll talk more about this as there is some really good stuff being posted here.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 22, 2008 11:37:08 AM
|
|
|
JSPT
Posts: 284
Joined: April 19, 2005
From: Michigan
Status: offline
|
I recently had an orthopod tell me that he doesn't like PROM performed on his TKA's. He thinks that patients are more likely to form scar tissue. I'm not too sure about that. Has anyone heard of that before?
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 23, 2008 8:53:45 AM
|
|
|
buckeye
Posts: 175
Joined: May 24, 2007
Status: offline
|
JSPT - do you think the surgeon was talking about passive stretching or passive range of motion? I suppose the surgeon could make a case for passive stretching. If stretching is not controlled or is too aggressive, it is possible to have tissue tears resulting in scar tissue.
My experience is most total knees lack flexion motion due to pain inhibition and swelling. It is likely the surgeon takes them through full range in surgery without restrictions, so if we tackle motion early it seems like we should not have much tissue shortening to stretch.
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 23, 2008 9:07:07 PM
|
|
|
jesspt
Posts: 85
Joined: April 3, 2007
From: Illinois
Status: offline
|
Buckeye,
I'll buy that, if the patient who has had a TKA has had appropriate rehab in the hospital and then either at a SNF or with a home therapist. But, way too often, I get the TKA who is three to four weeks status post TKA who has 10-75 degrees of flexion and has gotten a therapist who has given them SLRs (with no attention paid as to whether there is an extnesor lag) and some AROM, but no real fucos on improving their ROM. By this time, enough tissue shortening and scarring has occured, and I've got my work really cut out for me.
_____________________________
Jess Brown, PT
Board Certified in Orthopaedic Physical Therapy
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 23, 2008 9:21:30 PM
|
|
|
SJBird55
Posts: 2438
Joined: May 10, 2004
From: Michigan
Status: offline
|
Jess, I see the same darn thing in my area. Generally speaking the quality of care provided in the home sucks. Passive range of motion is horrible: 10 or 15 degrees from full extension to 60-75 degrees of flexion. The therapists or assistants never put a hand on them and only ahd them do active crap without any feedback.
I honestly believe that educating those patients on what is normal, the level of pain that is common, how long it is common and that the knee is never going to feel "normal" because there's metal in it. The density of metal is different than bone so they should never expect that knee to feel the same as "normal." I also believe addressing their fears goes a long way. I even make them deals - I let them know where I want to see their range after each week - I honestly don't stretch their involved knee much unless they aren't making gains on their own. I'm not really sure how I would describe what I do when I need to do anything, but I manually focus on their patella and I do joint mobilization and I do deep soft tissue work around the incision. If the patient attends outpatient therapy 5-7 days after the arthroplasy, my job is generally easy (unless there had been infection or a DVT or something unusual). If the patient had home health services for 4 weeks... uggghhh... I put on my fake happy face and realize that I'm going to have to work for the units billed.
I'm actually networking with some of the administrators and staff with a home health company that is just beginning to branch out into my area. I'm being an advocate for them and have communicated to physicians in my area about them. This company seems to have outcome numbers and that is WAY better than the 3 other commonly chosen companies because those 3 commonly chosen companies are affiliated with the hospital where the procedure was performed.
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 23, 2008 10:19:29 PM
|
|
|
Kaden
Posts: 335
Joined: June 17, 2007
Status: offline
|
I have lately been seeing the same thing with TKAs from home health. I always make it a point to ask them what they have been doing so I can incoroprate some of this into there care as it makes a nice continuim of services.
Lately I have also made a point of directly asking these patients, "did the therapist put there hands on your knee and do some stretching" and 85-90 percent of the time the answer is no. How a patient can come lacking 15 extension and with 75 degrees flexion and there has been no manual attempts at increasing range I do not understand.
What also gets under my skin is that the typical patient I have described above has had home health 3-4 times a week for 4 weeks.
If in outpatient I spent 12-15 visits to get those results I would have insurances companies and a physician breathing down my neck about why the lack of progress with 15 visits.
Any home heath PT's out there who can speak to this and suggest ways to improve situations like this.
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 23, 2008 11:02:53 PM
|
|
|
TexasOrtho
Posts: 560
Joined: December 22, 2007
Status: offline
|
Home health can be a whole other story here, and a mixed bag to be sure. Keeping in focus with the pupose of this thread, I noticed something earlier regarding how we use certain terms like "stretching" and "mobilization". I am guilty of this myself as I find myself using terminology with patients I don't use with colleagues, so it's easy for vernacular to get in the way with communication.
Let's consider the first postoperative week assuming ideal circumstances of no perioperative complications. What do you see as the primary imparments and how do you tie your specific intervention to addressing this impariment? Do patients need to be stretched or mobilized?
I'll throw this out there. I know some of this may seem elementary but it's more of a logical exercise so just hang in there with me: I perceive the primary impairments are the direct result of surgical event such as pain and intraarticular swelling. Under these circumstances I believe mid-range and relatively nonprovocative passive or active assisted movement often supplies nervous system with normal afferent stimulus to modulate pain and normalize the effusion. If this intervention is successful, both pain levels and control of swelling can be achieved early on and avoid complications of the later postoperative course. If this can be achieved actively through self-generated movement (vs manually induced movement), it's that much better.
Although I continue to perform them, I have a suspicion that activities such as end-range static positioning in either extension or flexion (i.e. stretching) may actually induce more nociception to an already-sensitized area in the early postoperative course. Secondly I think it does little to nothing to addressthe primary impairment of itnraarticular swelling. The mechanisms of pain due to static positioning (I believe) are primarily ischemic as tissues become "wrung-out" during static loading. Incidentally, this could be why patients report feeling much better and having more motion after they've performed gentle mid-range ROM. For patients I am lucky enough to see during the early postoperative phase, I am starting to phase out static positioning as a pilot program to see if I can get a better progression of function.
Stretching or static loading of specific tissue, should only be performed when we are certain that the limitation of motion is due to true restriction of collagenous structure. This can only be truly ascertained after pain control has been achieved and there is little to no muscle guarding. I haven't addressed education but this is probably the most important element of the process in my mind. My education of what postoperative pain is and is NOT has helped this process tremendously. It has allowed me to regulate maladaptive behaviors to a much greater degree.
Ok so this is my strategy for the initial postoperative phase up to 10-14 days. I'm ready to take shots, criticisms, or comments.
< Message edited by TexasOrtho -- July 23, 2008 11:12:20 PM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 24, 2008 6:23:44 AM
|
|
|
SJBird55
Posts: 2438
Joined: May 10, 2004
From: Michigan
Status: offline
|
If the patient had home health services, according to your perception of "stretch," those patients have stretching that has to occur because I have no idea how else to gain any motion when they walk in 4-5 weeks postoperatively with horrible motion.
How long is static?
With all patients that have had a TKA, I have them do static stretching into extension immediately - they are just sitting and watching TV. They are supposed to keep that knee in a stretched position until the back of the knee bugs them enough that they want to move it. Move it/wiggle and then go back into position. I have them do that for 10-15 minutes 2-4 times a day. OR they can lie on their belly and hang the leg off the bed - most don't do that though. The "stretch" force is just the force of gravity.
When patients come into the clinic that soon after therapy, I spend probably 10 minutes with manual intervention - feeling the joint, sometimes mobilizing the patella, joint mobilization - grade I-III depending on what I feel, and just a tad of what I'd call "stretching" but not necessarily with my hands, but with the patient moving the knee into the area of pain and providing encouragement to increase the range or feedback that they are progressing nicely as I measure and assess the change visit to visit. Then, I get them moving - recumbent bike - a good 5-10 minutes. I then have them begin the total gym bilateral squats. Snyder-Mackler has some awesome research out there involving continual weakness of the quads after TKA and function 1-2 years after TKA... she's looked at neuromuscular electrical stimulation. Mentally, I want to implement that, but the problem with her study is that I have no idea which patients are the appropriate candidates? Do I have them all get rentals no matter what? Only the ones with extensor lags? Extensor lags at what point in time?
Rod, I have no idea about your theory. It can't be right all the time because I have had men begin therapy 7 days after a TKA (and even a few women) who were basically walking without their walker (although they had it) and demonstrating 90 or more degrees of flexion. I believe you can't just focus on the body and it's processes but also need to consider the actual prosthesis and the components and the fit of the prosthesis. As therapists, we have no control over that.
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 24, 2008 6:42:02 AM
|
|
|
Sebastian Asselbergs
Posts: 1207
Joined: September 29, 1999
From: Barrie, Canada
Status: offline
|
SJ, I do not understand your last paragraph quote:
Rod, I have no idea about your theory. It can't be right all the time because I have had men begin therapy 7 days after a TKA (and even a few women) who were basically walking without their walker (although they had it) and demonstrating 90 or more degrees of flexion.
- as I read it, he suggests that static (long sustained) stretching is only really needed when collageneous tissue is the restricting factor. I think that the chance of that happening in that initial period (10-14 days post-op) is minimal.
And the men and women who already have 90 or more degrees of flexion 7 days post-op certainly wouldn't need any MORE stretching of any kind, would they? With that kind of early ROM, propriocepsis and function becomes more the focus, I think.
_____________________________
Mundi vult decipi
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 24, 2008 9:51:26 AM
|
|
|
buckeye
Posts: 175
Joined: May 24, 2007
Status: offline
|
I try to start the patients with some form of heel prop for passive extension as early as possible after surgery with a style similar to what SJBird describes - gravity stretch as long as tolerated, wiggle a little, then more gravity stretch to patient tolerance. I think the general concept of stretching structures only when we think soft tissue is the culprit makes sense - but I suppose you are not going to let someone hang out in 10-20 degrees of flexion the first week or two after surgery because it is comfortable.
Is this much different than post-op ACL repair? These patients' knees are very painful and swollen (hopefully those issues are addressed) but it is still crucial to perform heel prop or prone hang for gravity assisted passive extension.
TexasOrtho - How do you define the stretching you are avoiding immediately post-op? Is this just manual stretching? Does the heel prop for passive extension fit into your scheme of stretching?
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 24, 2008 10:12:01 AM
|
|
|
jesspt
Posts: 85
Joined: April 3, 2007
From: Illinois
Status: offline
|
This post seems to have taken a turn towards "how do we restore ROM in the early post-operative phase?" Do any of you really see a lot of TKAs who have had surgery 14 days ago or less? They just don't seem to make their way into my clinic. Maybe I'm in the minority; I don't know.
But, I do know that this thread would be more clinically useful to me if it focused on those patients we see that have awful ROM and get to us about 3 to 4 weeks after surgery. Anyone have any thoughts regarding these people?
_____________________________
Jess Brown, PT
Board Certified in Orthopaedic Physical Therapy
|
|
|
|
|
RE: Restoring postoperative knee ROM - July 24, 2008 11:41:44 AM
|
|
|
Kaden
Posts: 335
Joined: June 17, 2007
Status: offline
|
Jess,
I agree, I rarely see any TKA's within the first 2-3 weeks s/p. I also would benefit more from a discussion on how to handle the tougher patient lacking motion 4 weeks out. I never have much difficulty restoring range if I see them in the first week. Decreasing pain and letting the patient take a more active or active assistive approach and I'll step in manually if not progressing, this does the trick for me.
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.188
|
Printable Version
