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THR/TKR
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THR/TKR - August 20, 2000 5:52:00 PM
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pschwarz
Posts: 7
Joined: June 14, 2000
From: Ft. Lauderdale, FL, USA
Status: offline
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Hi, this is pschwarz. Thank you all for responding to my e-mail. You're right, perhaps I was being a little short on what type of response I was looking for. I assumed that someone out there could give me a more in-depth clinical view of how to treat a patient 10 days post-op THR. I've been reviewing a book titled Therapeutic Exercise Foundations and Techniques by Kisner and Colby. Although a very good reference, I find myself still struggling with how to apply the information I get out of a textbook to specific cases. After all, I'm only a student trying to reach out to other resources.
The case I was given is as follows:
It's now 10 days later, your patient with the THR is now home today. The case manager, a social worker, had met with him to discuss the DME and to arrange for delivery to his home. The delivery was made this morning and you are asked to see patient for home physical therapy.
Your other patient with the TKR is now 20 days post-op and is also at home.
Perform an assessment and treatment for Home Health Physical Therapy.
I'm hoping that someone could give me some advice on how to tackle this case. I'm trying to teach myself to think as a clinician. I want to take the knowledge that I'm gathering to the next level. Can you help?
This is what I'm thinking:
Pt. is at home. Should have enough strength for efficient ambulation. I should emphasize closed and open-chain strengthening exercises for the hip extensors and abductors, as well as, improving endurance in these muscles. Use light weights and high repetitions, keeping all precautions in mind. Is this too aggressive? Should I instead instruct pt. to perform AROM exercises and light resisted exercises using Theraband to develop neuromuscular control of the hip musculature. Have pt partial weight bear on affected side and avoid too much activity.
Am I on the right track? I know that I can be a little more aggressive with TKRs. However, being that reality is far different from what you read in a textbook, maybe someone can help lead me in the right direction. Thank you for your time.
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Re: THR/TKR - August 21, 2000 3:11:00 AM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
Status: offline
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Patricia,
Good thoughts. Personally, I'm a pediatric PT (who used to do a fair share of adult home health in a former life), but it's been quite a while since I've seen a patient with a joint replacement of any kind.
I'll let others on the forum take up with some of the other issues that you brought up, but G. Kelly Fitzgerald, PhD, PT presented a very interesting discussion with Susan Harris, PhD, PT and Diane Damio, PhD, PT at PT '99 two years ago regarding Challenging the Myths of physical therapy.
Open versus closed chain activity was Dr. Fitzgerald's topic area. I'm in the process of moving, but if you like, I'll make a copy of the audiotape from the presentation when I can put my hands on the tapes. E-mail me your address to Drewpt@e-machines.net and I'll see what I can do for ya.
Drew
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Re: THR/TKR - August 21, 2000 5:55:00 AM
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gary
Posts: 9
Joined: August 30, 1999
From: wantagh, ny
Status: offline
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Hi,
Your first assumption about efficient ambulation may be wrong. Hospital ambulation vs home ambulation may have no relationship
whatsoever. Concentrating on exercise alone is very narrowly focused. Look at bed mobilty (yes THR pt's are discharged still unable to independently get oob) Is this person living alone, or is he/she going to be left alone any part of the day? If so, can they get out of the home in case of a fire? You need to see the whole forest instead of the individual trees. I don't know if this will help your particular situation--if the focus is just on exercise--then disregard the above. BTW-wb status is determined by the surgeon.
Gary
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Re: THR/TKR - August 21, 2000 1:55:00 PM
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Dana D
Posts: 142
Joined: September 18, 1999
Status: offline
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You may also want to take a look at the physical environment of the house and make suggestions. For example
1. are there throw rugs? if so, can they be removed/taped down more securely? They are a huge factor for safety, related to a lot of falls.
2. Look at the type of chairs they have in their house... are some too low? to get out of? also, THR patients can not sit in something too low, or they may dislocate (flexion beyond 90 degrees)Do the chairs have arms to help them sit to stand... make suggestions in these areas.
3. What does their bathroom look like? do they need grab bars near the toilet? a shower chair? a transfer bench/shower chair combo...a grab bar in the shower? anti-slip mat in the shower? A lot of times local agencies have loan closets for this type of equipment....which can be loaned out temporarily for the person as they go through rehabilitation...
4. When they get to the point of stair climbing... is it possible to have an extra walker/cane upstairs for when they get there... so they don't have to carry one up with them. Can they get a basket on the front of their walker, to help them transport small objects around their house.
5. Sometimes patients can not physically walk the length of their home, initially... due to endurance and often influenced by fear... it may be a suggestion to place a chair, say in the hallway, or half way between point A to point B, to give them a place to rest and recoup... This could be used in goal setting, and placed at further distances as goals are achieved... eventually being removed.
Any other home modifications... not talking huge renovations or nothing, but simple brainstorming with the patient, to help make their environment safe and more efficient with them.
Good luck!
[This message has been edited by Dana D (edited August 21, 2000).]
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Re: THR/TKR - August 21, 2000 6:26:00 PM
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pschwarz
Posts: 7
Joined: June 14, 2000
From: Ft. Lauderdale, FL, USA
Status: offline
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I wanted to thank you for the wonderful ideas regarding Home Health Physical Therapy. We went over this topic in class today and you hit the nail on the head. You also bought up some other great ideas that that weren't mentioned. Thank you for being a part of my learning process. Enjoy your day!
[QUOTE]Originally posted by Dana D:
You may also want to take a look at the physical environment of the house and make suggestions. For example
1. are there throw rugs? if so, can they be removed/taped down more securely? They are a huge factor for safety, related to a lot of falls.
2. Look at the type of chairs they have in their house... are some too low? to get out of? also, THR patients can not sit in something too low, or they may dislocate (flexion beyond 90 degrees)Do the chairs have arms to help them sit to stand... make suggestions in these areas.
3. What does their bathroom look like? do they need grab bars near the toilet? a shower chair? a transfer bench/shower chair combo...a grab bar in the shower? anti-slip mat in the shower? A lot of times local agencies have loan closets for this type of equipment....which can be loaned out temporarily for the person as they go through rehabilitation...
4. When they get to the point of stair climbing... is it possible to have an extra walker/cane upstairs for when they get there... so they don't have to carry one up with them. Can they get a basket on the front of their walker, to help them transport small objects around their house.
5. Sometimes patients can not physically walk the length of their home, initially... due to endurance and often influenced by fear... it may be a suggestion to place a chair, say in the hallway, or half way between point A to point B, to give them a place to rest and recoup... This could be used in goal setting, and placed at further distances as goals are achieved... eventually being removed.
Any other home modifications... not talking huge renovations or nothing, but simple brainstorming with the patient, to help make their environment safe and more efficient with them.
Good luck!
[This message has been edited by Dana D (edited August 21, 2000).][/QUOTE]
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Re: THR/TKR - August 21, 2000 6:30:00 PM
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pschwarz
Posts: 7
Joined: June 14, 2000
From: Ft. Lauderdale, FL, USA
Status: offline
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Thank you for responding. I'm working on trying to see the whole forest. I'm just starting my second year, I have a lot of fine tuning to do. Thanks again!
[QUOTE]Originally posted by gary:
Hi,
Your first assumption about efficient ambulation may be wrong. Hospital ambulation vs home ambulation may have no relationship
whatsoever. Concentrating on exercise alone is very narrowly focused. Look at bed mobilty (yes THR pt's are discharged still unable to independently get oob) Is this person living alone, or is he/she going to be left alone any part of the day? If so, can they get out of the home in case of a fire? You need to see the whole forest instead of the individual trees. I don't know if this will help your particular situation--if the focus is just on exercise--then disregard the above. BTW-wb status is determined by the surgeon.
Gary[/QUOTE]
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