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RE: Restoring postoperative knee ROM
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RE: Restoring postoperative knee ROM - July 24, 2008 12:20:27 PM
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TexasOrtho
Posts: 541
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First let me clarify. I still perform static prolonged extension and flexion "stretching". My current recommendation is for the patient to perform the extension stretch for 5-10 minutes at a time 3-5 times per day. I will encourage similar activity for flexion only as needed. I seem to place more emphasis on extension in the early postoperative phases of any knee procedure.
I've got no problem taking the discussion anywhere you guys/gals want. I do see many patients within the first postoperative week, so the early stuff is pretty meaningful to me. It does beg the question however, if we don't see them this early, shouldn't we have some guidelines for therapists who do? In this sense, I think the discussion of early postoperative intervention is important. It's also relevant to how the patient presents 3-4 weeks out.
I also agree that discussing complicated patient cases would be very beneficial as they can be trying. However, it would seem that some general theoretical guidelines for a nominal course could form the basis for treating more complicated cases. It may be tedious, but guidelines for early, middle, and late stage recovery could lay the groundwork for more difficult situations. I'd welcome discussion on any of these issues.
I get very good results with TKA using static loading (or stretching) as described above. However, the question in my mind is whether there is a better conceptual mousetrap with fewer adverse events (less pain specifically) that can achieve the same progression of motion. If we have the choice between two equally effective interventions and one happens to elicit less nociception, it would make sense to pursue that option.
We can talk about this process at any stage. At the conclusion of the discussion, it might be interesting to develop this into some general guideline or recommendations for regaining motion at various stages of postoperative recovery. Again, I'm doing this primarily as a mental exercise as I like to connect the dots between what I do and what is actually occurring within the patient.
< Message edited by TexasOrtho -- July 24, 2008 12:28:36 PM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Restoring postoperative knee ROM - July 24, 2008 1:17:49 PM
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Kaden
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Good post Rod. I may have jumped the gun in saying lets take this into a discussion of the complicated knee. You are right, it is more important to develop these guidelines for care early on in order to avoid the "troublesome" knee walking through our doors.
It would be nice at the end of this to develop some management guidelines for regaining motion at various stages. I would even love to meet with some physicians or even home health PTs in my area to discuss some general guidelines.
If ortho MD, home health PT and outpatient PT were on the same page about progressing range through the rehabilitation process it would create a proactive environment to avoid those tough cases.
As a side not Rod, how do you get these patients in the first week? In my neck of the woods the patients are always in home care first? I would love that, not b/c I don't think some home health PTs can do a good job with these, but more b/c if I am going to be responsible for the long term outcome of this knee I would like to have control as to how the rehabilitation process begins.
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RE: Restoring postoperative knee ROM - July 24, 2008 5:32:00 PM
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buckeye
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Joined: May 24, 2007
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jesspt and kaden - patience.
I think TexasOrtho is taking this thread in steps for post-op care. There are some surgery centers who send patients with TKAs home the same day or next day, so the first couple of weeks post-op are still relevant for some clinicians.
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RE: Restoring postoperative knee ROM - July 24, 2008 6:22:29 PM
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jesspt
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From: Illinois
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Lead the discussion where you will; I've no objection to staging the rehab recommendations for these folks, but I would echo Kaden's sentiments that, on the rare occasion when I get them early, I just don't seem to have any trouble getting ROM back.
Rod, your stating that the static loading is painful for your patients, and it seems you advocate a minimum of 15 minutes of total end range time for your patients. This seems reasonable to me. Do most of your patients who are compliant with this come back to you and report extreme increases in pain and/or swelling? I guess that I haven't seen this, but as I mentioned in this and other posts, I don't see these people acutely.
< Message edited by jesspt -- July 24, 2008 10:18:22 PM >
_____________________________
Jess Brown, PT
Board Certified in Orthopaedic Physical Therapy
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RE: Restoring postoperative knee ROM - July 24, 2008 7:21:00 PM
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SJBird55
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From: Michigan
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Bas, if you read articles that are in Bone and Joint or something like that, there are some interesting ones on TKA. The components and the surgical procedure are factors. From reading those articles, I made the mental connection that poor technique and a poor fit component would lead to both increased pain and decreased motion.
Unlike Rod, I hammer extension just as equally as flexion. In my opinion, both movements are required - extension for normal gait and flexion for going down stairs normally. Flexion is more scary for patients because they think their components are going to pop out their incision.
I have always wondered how the surgeon determines who has home health or who has outpatient services after the procedure. In this area, toss a coin. The ones that I have seen day 5-7 after the procedure progress more quickly and seem to be happy with their situation after 8 weeks of therapy initially 3 days a week the first week and then 2 days a week for 4 or 5 weeks and then 1 day a week. The one day a week is because most of the patients seem to have a fear that they will lose motion and also generally want feedback from me on their performance and progressing their activities.
Therapy after a TKA is generally painful - I don't expect anything different. The interpretation of that pain by the patient is what matters the most, in my opinion.
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RE: Restoring postoperative knee ROM - July 24, 2008 10:10:22 PM
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TexasOrtho
Posts: 541
Joined: December 22, 2007
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[font=advtt2cba4af3.b] From the Journal of Arthroplasty. This isn't a joke. According to this study, we are just as effective as a music video but $2300 more expensive. Yikes...this probably won't make it into my marketing brochures. There are several good studies in Arthoplasty on rehabilitation following TKA and THA. Anyone else have a problem with this? Maybe more activity and initiative on our part could get us a seat at this table. We should be leading investigations on rehabilitation following arthroplasty, not surgeons who know little to nothing about physical therapy. Studies like this imply that there are cheaper, easier, and less time-consuming alternatives to therapy following TKA. My take home is that we may want to step it up in this arena in defining our expertise lest we gradually loose this population to Brittany Spears. POSTOPERATIVE TOTAL KNEE ARTHROPLASTY REHABILITATION: A NEW METHOD USING MUSIC VIDEO Thomas G. Ryan, MD, Blake Ohlson, Ryan Adams [font=advtt2cba4af3.b]Introduction: Postoperative rehabilitation protocols after total knee arthroplasty vary considerably among surgeons. Previous reports have shown the usefulness of music exercise videos for cardiovascular rehabilitation and general fitness. The authors created a music exercise video for use in the postoperative period after total knee arthroplasty. Abstracts from the AAHKS Sixteenth Annual Fall Meeting [font=advtt2cba4af3.b] Methods: A prospective study was done whereby 45 patients undergoing 51 primary total knee arthroplasties were randomized to a control (25) or video (26) group. All procedures were done by the senior author. All patients were evaluated at postoperative weeks 1, 2, 4, 6, and 8 by a blinded examiner who generated Knee Society scores. Patients also completed a satisfaction questionnaire, and the 8-week cost of rehabilitation was documented. [font=advtt2cba4af3.b] Results: Significant improvements were noted in patient’s assessment of understanding, confidence, and overall satisfaction when using the video ([font=advttf90d833a.i]P b .05). Average return to usual activities was 34 days in the control and 14 days in the video group ([font=advttf90d833a.i]P b .0001). Knee Society knee and function scores were improved for the video group and were statistically significant for the 6- and 8-week scores ([font=advttf90d833a.i]P b .05). The therapy costs averaged $2602.00 in the control and $287.00 in the video ([font=advttf90d833a.i]P b .0001). No complications were reported while using the video. [font=advtt2cba4af3.b] Discussion: Use of the music video as a supplement to the rehabilitation program after total knee arthroplasty is recommended because of improved patient satisfaction, earlier return to activities, and improved knee scores. These are achieved at a substantial cost savings that benefits both patients
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Restoring postoperative knee ROM - July 24, 2008 10:22:18 PM
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TexasOrtho
Posts: 541
Joined: December 22, 2007
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Here's one we can jump on: Lavernia CJ, D'Apuzzo MR, Hernandez VH, Postdischarge Costs in Arthroplasty Surgery. Arthroplasty Volume 21:6 Suppl. 2 2006
From the discussion: Clearly, postrehabilitative outcomes after joint arthroplasty surgeries must be better defined in an effort to provide meaningful treatments that are efficient and cost-effective. In the coming years, it will be necessary to identify evidence-based rehabilitation strategies that will promote functional recovery after knee and hip joint arthroplasty as quickly and safely as possible while maximizing functional abilities. It is also important to select the least expensive option under the scenario of equally effective rehabilitative approaches. The only way to truly evaluate the utility and costeffectiveness of these postsurgical rehabilitative strategies is to perform well-designed multicenter randomized clinical trials. These trials are not only critical for maximizing patient outcomes, but may also help to at least slow the growth of annual expenditures associated with arthroplasty. -----
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Restoring postoperative knee ROM - July 31, 2008 9:55:45 AM
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buckeye
Posts: 170
Joined: May 24, 2007
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TexasOrtho - I am disappointed this thread is not generating any responses. Maybe it is summer and people are on holiday. I agree the PT should be leading the cause of post-op rehab programs. Maybe the forum is not ready or not the best place to develop a model.
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