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    presentation at Hosp Sultanah Bahiyah presentation at Hosp Sultanah Bahiyah Presentation Transcript

    • Adlin Hani binti Mazlan Hanafi 2011445252 UiTM Puncak Alam PTY 309 Osteoarthritis with Total Knee Replacement (TKR)
    • ANATOMY
    • • Knee joint is the largest and most complex joint. • The upper bone is the femur and the lower bone is the tibia. The small bone at the lateral side is the fibula. The knee cap (patella) is in front of the knee. • There are large muscles in the front of the thigh (the quadriceps) and back of the thigh (the hamstrings). • Ligaments join the knee bones and provide stability to the knee: -The anterior cruciate ligament prevents the femur from sliding backward on the tibia (or the tibia sliding forward on the femur). -The posterior cruciate ligament prevents the femur from sliding forward on the tibia (or the tibia from sliding backward on the femur). -The medial and lateral collateral ligaments prevent the femur from sliding side to side. • Two C-shaped pieces of cartilage called the medial and lateral menisci act as shock absorbers between the femur and tibia. • Numerous bursa, or fluid-filled sacs, help the knee move smoothly. (G. J Tortora, 2009)
    • PATHOPHYSIOLOGY • Osteoarthritis is a deterioration and changes happened mostly at the knee where articular cartilage that cushions the bones breaks down, and causes the bones to rub together. • Articular cartilage is living tissue. The growth and repair will decreases with age. • Elasticity and viscosity of synovial fluid changes as hyaluronic acid concentration decrease. • This results in the formation of ulcers that extend deep into the bones. • The surfaces of the knee gradually "wear out“ and creates pain, swelling, and stiffness. • Weight-bearing activity becomes painful, often limiting physical activity. • After a while bone spurs may form and ligaments and muscles around the joint become weaker. (OA health Center, 2009)
    • Total Knee Replacement • Osteoarthritic of the knee is the commonest reason which necessitates knee replacement. • Total knee replacement (TKR) is a surgery where only the worn-out cartilage surfaces of the joint are replaced. • The operation (also called knee arthroplasty) is basically a "re- surfacing“ of the knee joint because only the surface of the bones are actually replaced. • When the patient having a TKR, the surgeon removes damaged cartilage and bone from the surface of the knee joint and replaces them with a man-made surface of metal and plastics. • A small amount of bone is removed, the collateral ligaments are left intact, and the muscles and tendons are left intact. (AAOS, 2011)
    • Clinical Presentation • Pain is felt around the knee join • Joint stiffness usually lasts less than 20 minutes • Limitation of movement • Loss of function • Affected joints may have tenderness and firm swellings at the joint • Decreased range of motion (ROM). • Worse with weight bearing and ambulation. • May be cartilaginous crepitus or a crackling feeling on palpation. There may be coarse. • Malalignment of the leg with a varus deformity or bow-legged positioning of the leg d/t loss of cartilage. (OA health Center, 2009)
    • Dr Management • Other treatment options before surgery : i) Medications : NSAIDs ii) Medications injected into the joint : Corticosteroid injections fight inflammation iii) Creams or ointments to rub onto the skin iv) Exercise and physical therapy : Exercise strengthens the muscles that support the knee v) Weight loss : Every pound a person gain puts an extra 3 pounds of pressure on the knees vi) Nutritional supplements • If these treatment options don't relieve the pain well, less effective, not tolerable, the doctor may suggest surgery. i) arthroscopic surgery : involves small incisions to remove pieces of cartilage and trimmed the damage tissue to smoothen the joint surfaces ii) knee replacement surgery : replacing the damaged parts with an artificial joint. These are made of metals and plastics (OA health Center, 2009)
    • PT Management • Exercise to improve strength, flexibility balance and maintain joint motion • Electrotherapy • Taping • Use of a knee brace or compression bandage • Ice or heat treatment • Hydrotherapy • Education • Anti-inflammatory and supplement advice (e.g. glucosamine and chondroitin) • Weight loss ( Leonard Ong Yao Jian, 2011)
    • CASE STUDY
    • Subjective Assessment Name : Mrs. J Age : 60 years old Gender : Female R/N : AS00****** Location : Outpatient ( Gymnasium) D.O.A : 28/04/2013 D.O.R : 04/02/2013 Race : Indian Dr. Diagnose : Bilateral knee OA Dr. Mx : TKR Rt knee. Planned for Lt knee 6 months after.
    • Patient’s Problem : 1. Pt c/o mild uncomfort at both knee during walking 2. Pt c/o need mild assisstance during sitting to standing 3. Pt c/o need assisstance to climb up stairs
    • BODY CHART VAS : (Rt) 0/10- rest 3/10- on movement (Lt) 0/10- rest 4/10- walking Agg : bend Rt knee towards 90° Ease : rest/sitting Nature : pulling pain on both side posterior thigh Irritability : low 24 h : intermittent pain (depends on movt) TKR incision site
    • Current History : Pt done post TKR for Rt knee on 29/01/2013. Having complicated patella tendon medial 30% tear on Rt knee during manipulation, repaired with prolene 2/0. After 3 months, pt able to walk without walking aids. She is having good improvement. Pt is not allowed to do Rt knee flexion more than 90° yet. Doctor planned for Lt knee TKR, 6 months after the Rt side which is on Aug 2013. Past History : Having bilateral knee OA since 2011. Intraarticular injection hyaluronic acid was given 1x on 31/10/2011 but was not helpful. No history of fall or accident. PM History : Rt breast carcinoma. Done mastectomy and axillary clearance on 2009. on follow-up every 6 months - on T.tamoxifen 20mg OD
    • Special Question General health: healthy Weight loss : nil Smoking : nil Social History Occupation : Retired officer Status : Married. Having 2 daughters and a son. House Environment : single storey house – staying with husband and a daughter Activities : Indoor activities. Not involved any vigorous activities.
    • Observation General : A medium sized old Indian lady came to department independently. Walking without aids. Walking with slight limping gait towards Lt side, slow and careful. Looks healthy and cooperative. Local : No swelling, no redness, no dry skin on both knee. Palpation : No warmness, no tenderness, no muscle spasm on both knee
    • Objective Assessment Range of Motion (ROM) Joint Movement Rt active Rt passive Lt active Lt passive Normal Hip Flexion AFROM - AFROM - 0-120° Extension “ - “ - 0-20° Abduction “ - “ - 0-45° Adduction “ - “ - 0° Knee Flexion -10°-75° -10°-75° -40°-90° -40°-90° 0-120° Extension Ext lag 10° - Ext lag 40° - 0° Ankle Dorsiflexion AFROM - AFROM - 0-20° Plantarflexion “ - “ - 0-50° Int : Reduce joint ROM both knee d/t pain and muscle tightness
    • Manual Muscle Testing (MMT) Muscle Rt Lt Hip Flexor 5/5 5/5 Extensor “ “ Abductor “ “ Adductor “ “ Knee Flexor 4/5 (with limit ROM) 4/5 (with limit ROM) Extensor 4/5 (with limit ROM) 4/5 (with limit ROM) Ankle Dorsiflexor 5/5 5/5 Plantarflexor “ “ Int : Reduce muscle power knee flexor and extensor both knee d/t muscle weakness
    • Muscle Bulk From base of patella Rt (cm) Lt (cm) Differences 5 cm (VMO) 51.0 51.5 0.5 10 cm (Quadriceps) 53.0 53.0 0 15 cm (Hamstrings) 55.0 55.0 0 From apex of patella 13 cm (Gastrocnemius) 41.5 40.5 1.0 Int : Normal muscle bulk for both LL
    • Patella mobility Movement Rt Lt Superior glide Less mobile Crepitus Inferior glide Less mobile Crepitus Medial glide Less mobile Crepitus Lateral glide Less mobile Crepitus Int : Crepitus found on Lt knee d/t degenerative changes Less mobile of patella on Rt knee d/t lack of activities
    • Sensation test : Hot and Cold Special test Lt Knee Patella Grinding Test : +ve Dermatome Rt Lt L1 Intact Intact L2 “ “ L3 “ “ L4 “ “ L5 “ “ S1 “ “ S2 “ “ S3 “ “ Int: Skin sensation intact on both LL
    • Analysis Problem Impairment Functional limitations Participation restrictions Pain at Lt knee d/t degenerative changes Unable to sit on the floor Unable to join family gathering Reduce patella mobility on both Lt knee d/t degenerative changes Difficult to perform sitting to standing from the chair Difficult to meet friends and attend event Reduce Rt and Lt joint ROM knee flexion and extension d/t prolonged immobilize Difficult to perform sitting to standing from the chair Difficult to meet friends and attend events Reduce muscle strength for Rt and Lt knee flexor and extensor d/t muscle weakness Difficult to climb up stairs Feel uncomfortable to go shopping Limping gait d/t uneven weight bearing caused by pain Unable to walk fast Feel tired to walk far and involved in any activities
    • Short Term Goal 1. To reduce pain on Lt knee from 2/10 to 0/10 within 1/7 2. To improve joint ROM for Rt and Lt knee flexion and extension within 1/12 3. To reduce hamstring tightness on both knee within 1/12 4. To improve muscle strength for Rt and Lt knee flexor and extensor within 3/12 5. To improve walking pattern within 6/52 6. To maintain balance and weight bearing within 2/12 Long Term Goal 1. To optimize maximum functional activity and improve ADL such walking and sitting to standing.
    • PLAN OF TREATMENT INTERVENTION EVIDENCE BASED Pain Management - Heat modalities i) Hot pack To reduce pain & improve blood circulation of Lt knee -Pt. in long sit.,apply hot pack on skin of Lt knee, 20 mins. The effects of thermotherapy are used clinically to control pain,increase soft tissue extensibility and accelerate healing. (Cameron M. ,2009) Therapeutic Exs - Active exs i) Knee flexion and extension - pt sitting on chair, perform knee flexion and extension actively; 20x; 3reps, 2x/day ‘Exercise to improve or eliminate impairments in thigh muscle flexibility and strength, and improve performance of endurance activities with repetitions.’ (James Rainville, MD,2004)
    • PLAN OF TREATMENT INTERVENTION EVIDENCE BASED - Stretching exs i) Hamstring stretch To reduce hamstring muscle tightness -Pt in long sit., towel at sole with both end hold by both hand, elevate leg till feel stretch at hamstrings, perform both LL, hold 15 secs, 15 mins ii) TA stretch to maintain ankle joint ROM -Pt in long sit., towel at sole with both end hold by both hand, pull the end towel to stretch the TA, perform both LL, hold 15 secs, 15 mins Holding stretches for 15 seconds, as opposed to five seconds, may result in greater improvements in active ROM. ( Roberts J M, 1999)
    • PLAN OF TREATMENT INTERVENTION EVIDENCE BASED - Strengthening exs i) IRQ To improve quadriceps muscle strength -Pt. in long sit., both below knee supported with tumble foam, do alternate IRQ, 10 secs, hold, 15 mins ii) VMO with ball To maintain VMO strength -Pt. in high sitt., put a soft ball between thigh, ask pt. to squeeze the ball, lift up both leg, hold 10 secs, 15 mins For most tears, some simple exercises can help maintain muscle strength in the front of the thigh (quadriceps), back of the thigh (hamstrings), calf, and hip. ( Freddie H. Fu, 2010)
    • PLAN OF TREATMENT INTERVENTION EVIDENCE BASED Pt Education - Avoid to put more stress on Lt knee that may trigger the pain - Advice on wearing knee guard HEP Continue exs as taught at home
    • Evaluation 1. Pt able to follow command and understands the treatment 2. Pt not complained any uncomfortable during exercise 3. Pt can tolerate with the exercise given and willing to continue exercise at home
    • Review Planned to have next follow- up on 21/05/2013 • KIV for posture analysis • Reassess on pt. both knee pain • Reassess on pt. ROM and muscle power for both knee • Reassess on pt. walking pattern for both LL • Continue all treatment done on next visit within pt toleration.
    • Follow Up 21/05/2013 S : i) Pt told that pain had reduced on Rt knee when walking from 2/10 to 0/10 ii) Pt c/o slight unstable during walking towards Lt side ii) Pt c/o pain at Lt knee had worsen with vas 4/10 when walking iv) Pt still claims of pulling pain at posterior thigh especially when get up from sitt. O : Pt came to department independently w/o walking aids. Able to drive auto car alone. Her limping gait obviously seen d/t Lt knee had worsen the pain. Looks healthy and cooperative. She brought along referral letter from Dr to allow Rt knee flexion towards 90°. Palpation : no swelling, tenderness, redness, dry skin on both knee
    • Posture Anterior view : Left sh. is slight lower than right sh. Lt ASIS is lower than Rt ASIS Lt knee is not align with Rt knee Lt knee not fully extended Posterior : Lt scapula is slight lower than right side Lt sh is lower than Rt sh. Lt popliteal lower than Rt popliteal Weight bearing more on Rt LL Lateral : Both knee not fully extended – Lt side more flexed than Rt side
    • ROM MMT Joint Action Rt active Rt passive Lt active Lt passive Knee Flexion -5°-80° -5°-80° -35°-90° -35°-90° Extension -5° -5° -35° -35° Int : Reduce joint ROM for both knee flexion and extension d/t pain and muscle tightness Muscle Rt Lt Knee flexor 4/5 4/5 extensor 4/5 4/5 Int : Reduce muscle power knee flexor and extensor both knee d/t muscle weakness
    • Patella mobility Muscle Bulk same as previous AX A : I. Pain at Lt knee d/t degenerative changes II. Reduce joint ROM for Rt and Lt knee flexion d/t pain and muscle tightness but has improves from last visit III. Reduce muscle power for Rt and Lt knee flexor and extensor d/t muscle weakness IV. Abnormal posture d/t muscle tightness and pain of Lt LL
    • Short Term Goal 1. To reduce pain on Lt knee from 3/10 to 1/10 within 1/7 2. To improve joint ROM for Rt and Lt knee flexion and extension within 1/12 3. To reduce hamstring tightness on both knee within 1/12 4. To improve muscle strength for Rt and Lt knee flexor and extensor within 2/12 5. To improve walking pattern within 6/52 6. To maintain balance and weight bearing within 2/12 7. To correct posture within 6/52 Long Term Goal 1. To optimize maximum functional activity and improve ADL such walking and sitting to standing.
    • PLAN OF TREATMENT INTERVENTION EVIDENCE BASED Pain Management - Heat modalities i) Hot pack To reduce pain & improve blood circulation of Lt knee -Pt. in long sit., apply hot pack on skin of Lt knee, 20 mins. The effects of thermotherapy are used clinically to control pain, increase soft tissue extensibility and accelerate healing. (Cameron M. ,2009) Therapeutic Exs - Stretching exs i) Hamstring stretch To reduce hamstring muscle tightness -Pt in long sit., towel at sole with both end hold by both hand, elevate leg till feel stretch at hamstrings, perform both LL, hold 15 secs, 15 mins ‘Exercise to improve or eliminate impairments in thigh muscle flexibility and strength, and improve performance of endurance activities.’ (James Rainville, MD,2004
    • PLAN OF TREATMENT INTERVENTION EVIDENCE BASED - Active exs i) Knee flexion To improve knee ROM - Pt side ly on Lt side, perform Rt knee flexion actively, 20x; 3 reps/day ii) Bean ball for knee flexion - pt sup ly, bean ball under both popliteal, actively perform knee flex and ext; 20x Active range-of-motion exercises for the knee may reinforcing, with repeated gentle challenges to the end ranges of movement in Osteoarthritis of the Knee. ( Deyle, G D, 2000) - Strengthening Exs i) Quad bench To strengthen the quad muscles - pt sitt on quad bench, weight 1kg, hold for 8 secs, perform for both LL, 15mins After acute symptoms subsided, exercises should be performed in open chain and closed chain positions to improve strength and endurance in isolated muscle groups and to prepare the patient for functional activities. (Kisner C. & Colby L. A.,2007)
    • PLAN OF TREATMENT INTERVENTION EVIDENCE BASED ii) Hamstring bench To improve ROM of knee flexion. pt sitt on hamstring bench, weight 1kg, hold for 8 secs, perform for both LL, 15mins Pt Education Avoid to put more stress on Lt knee that may trigger the pain - Advice on wearing knee guard HEP Continue exs as taught at home Evaluation 1. Pt able to follow command and understands the treatment 2. Pt not complained any uncomfortable during exercise 3. Pt can tolerate with the exercise given and willing to continue exercise at home
    • Review 1. Reassess on pt ROM and muscle power for both knee 2. Reassess on Lt knee pain 3. Reassess on pt. walking pattern for both LL 4. Continue all treatment done on next visit with pt toleration.
    • Conclusion Total knee replacement has proven to be successful and beneficial to modern surgery. Even not all patients with osteoarthritis get back their normal knee actions as normal person, but most patients enjoy many years of painless knee function with no limits on their ability to stand, walk and perform other activities of normal daily living. The rehabilitation programme may takes time but the effectiveness of TKR more or less will depends on the patients compliance itself. The most important thing is the physicians have to let the patients know that TKR is a life-enhancing surgery, not life-saving surgery.
    • References • Anonymous (n.d). Total knee replacement, Joint Replacement Institute, St Vincent Medical Center. Retrieved May 1, 2013 http://www.jri- docs.com/knee/KneeReplace ment/Resources /Pages/TheGoalsofTotalKnee Replacement.aspx • Anonymous, (2011). Total knee replacement, American Academy of Orthopedic Surgeon. Retrieved May 2, 2013, http://orthoinfo.aaos.org/topic.cfm?topic=a00389 • Anonymous, (2012). Total knee replacement, Southern California Orthopedic Institute. Retrieved May 10, 2013, http://www. scoi .com /total-knee- replacement.php • Carolyn Kisner and Lynn Allen Colby (2002). Therapeutic Exercise, Foundations and Techniques. 5th Ed. Davis Company, Philadelphia. • G. J. Tortora and B. H. Derrickson (2009).Principles of anatomy and physiology. 12th Ed. John Wiley and Sons, Inc. • Palmer S.H. (n.d). Total knee replacement. Retrieved May 12, 2013, http://www.kneeclinic.com.au/papers/TKR/tkrchapter.htm • Zelman, D. (2013). Knee Osteoarthritis: When to Consider Surgery. Retrieved April 30, 2013, Webhttp://www.webmd.com/osteoarthritis/osteoarthritis-knee- replacement-surgeryMD