Rehabilitation following THR and TKR.pptx

Dr Kaushal Raj Kafle, MBBS at Dhulikhel Hospital
Apr. 2, 2023

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Rehabilitation following THR and TKR.pptx

  1. Rehabilitation following THR and TKR Dr. Kaushal Raj Kafle Moderator : Asst Prof Dr. Prayoush Neupane
  2. Contents • Rehabilitation following THR – Preoperative – In hospital – Dos and Donts – Home based therapy • Rehabilitation following TKR – Preoperative – In hospital – Dos and Donts – Home based therapy
  3. Determinants • Preoperative Diagnosis • Surgical Approach – Posterolateral vs anterolateral • Cemented vs Non cemented Prosthesis • Primary vs Revision Surgery • Comorbidities
  4. THR Rehabilitation • Phase I : Prehabilitation • Phase IIa – Immediate Post Op Phase (0- 2days ) • Phase IIb – Late post op Phase (2 day -discharge) • Phase III – Strengthening Phase (2-12 Weeks) • Phase IV – Advanced Phase (12 Weeks and Beyond)
  5. Preoperative (Phase I) • Prior to surgery – Goal : THR precautions, basic post operative phases – Few days before surgery – Assessment : • Strength (UE and LE) • ROM • Neurological Status • Functional Status • Preoperative Hip Score – Safety adaptation at home/care centre
  6. • Upper limb : Grip/ Shoulder/ Elbow • Hip : Abductor+ gluts strengthening Flexors + adductor stretching • Lungs: Comorbidities + Ventilatory muscle training • Use of assistive devices • Safe transfer and transition techniques
  7. • Complication following Primary THA (2-10%) – THA dislocation (17.7 %) • Neuromuscular factor • Age > 80 • Non compliance
  8. THR precautions • Posterior/Posterolateral – No hip flexion past 90 degrees – No hip internal rotation – No hip adduction past midline • Anterior/Anterolateral – No full hip extension – No full external rotation • Trochanteric Osteotomy – Avoid Hip Abduction
  9. Early Hospital Phase • 1st and 2nd POD • Goal – Prevent complication – Reinforce THR precaution – Improve muscle contraction and control • Limitation: Post op pain, poor respiratory exchange,
  10. • Day 1 – Abduction pillow – Isometric: quad sets, glut sets – AROM: Ankle pump – Incentive spirometry – Bed side mobilisation • Day 2 – Transfer training – Weight bearing as per physician order – Gait training with use of assistive devices
  11. Late post op Phase (IIb) • Day 3 – Prerequisite : tolerance to previous therapy – No significant increase in pain or feature of infections • Goal – Improve LE AROM – Improve arm strength – Independent transfers and use of assistive devices – Carryover precautions for home based therapy
  12. • Continue Phase IIa – AROM : Heel slides, Active assisted hip abduction, Terminal knee extensions – UE exercises – Transfer training – Gait training – Evaluation of equipment at home and caregiver training
  13. • Hip Abduction – Supination – Standing – Sideline (Anti gravity)
  14. Ambulation and Weight Bearing • Non Weight Bearing • As early as day 1 • General condition • Pain intensity • Fever • On oxygen therapy • Hb : Requiring transfusion • Postural hypotension • Post operative delirium
  15. Return to Home (Phase III) • Discharge Criteria : – Independence with THR precautions – Independence with transfers – Independence with exercise programs – Independence on gait on level surface • 1-6 weeks Goal : Patient independence with transfer and ambulation Plan to return to work or community activity
  16. • Suture removal at D14 • Sitting and sleeping positions • Home based adjustment on furniture and amenities • Postural assessment • Adductor stretching and hamstring stretching • Balance and Core trunk strengthening exercises
  17. • Shoe adaptation • Progression from 4 wheeled walker to single cane (3-4 weeks ) • Non weight bearing > PWBM > FWB with crutches • Unsupported Gait training
  18. After 3 months • Open Chain and Closed Kinetic exercises • Sidestepping exercise • Modified Lunges • Aerobic conditioning • Step over step stair climbing
  19. Muscle Specific Exercises Categories Early Phase 1 (Weeks 1-6) Mid Phase 2 (Weeks 7-12) Late Phase 3 (Weeks 13- 16) Knee Extensors Quad Set SAQ SLR LAQ Resisted knee extension (thera-band) Wall squats Heel touch off a step 6’’ Hip Extensors Gluteal sets Supine Bridges Standing Hip Ext Mini wall squat Advanced Bridges (resistance band, single leg) Step ups onto raised boxes Hip Abductors Supine Abd Heel slide Weight shift SL balance (hands) Standing hip Abd Step out-in Clamshells SL balance (no hands) SL Hip Abd 4 way Resisted side step Single leg stance, raised limb push into wall Plantar Flexors Bilateral heel rises (hand hold) Bilateral heel rises Single heel rises Dosage Every day Everyday – Every other day Every other day
  20. OPD clinics • Physically Demanding patients – Additional strength and endurance training • Not fulfilling Home based therapy Requirements – Lingering gait • Weight shifting • Hip strengthening exercises
  21. Athletic Activities following THR
  22. The DONTS following THR
  23. Total Knee Replacement
  24. Preoperative phase • Patient education • Behavioral and health modification for joint protection • Cardiovascular conditioning • Life style modification : Including weight loss • Address flexibility and strength • Functional training
  25. • Familiarization with surgical procedures and phases of rehabilitation • Quads strengthening/ Hamstring Stretching • Patellar mobilization • FFD : Posterior capsule, hamstring and calf stretching
  26. Inpatient acute care • Time 1-5 days after surgery • Goal : – Prevent complication – Reduce pain and swelling – Promote ROM – Restore safety and independence
  27. • Position • AROM : ankle pump, circumduction • PROM : knee extension and flexion, supine heel slide • Isometric: quad, hamstring, gluteal sets
  28. • Chest physio and incentive spirometry • Transfer and bed mobility trainings
  29. Day 2 : • A/AROM : • AROM with heel slides in supine and sitting position • Terminal knee extensions • SLR
  30. Ambulation • Progressive gait training as tolerated with assistive devices • Weight bearing to tolerance • Day 1-2 • Ambulation – General condition – Pain intensity – Fever – Oxygen Requirement – Hb : Requiring transfusion – Postural hypotension
  31. Discharge Criteria • Patient able to demonstrate 80-90 degree of motion • Transfer supine to sitting, sitting to standing independently • Ambulate 15-100 feet
  32. Extended care (Phase IIa) • 6-15 days • Goal : – Self management of pain and edema – Independent bed mobility and transfers, independent gait – Knee PROM 0-100 – Use of assistive devices – Advance independence with home exercise – Functional lower extremity strength
  33. • Continuation of phase II with aggressive knee extension and flexion exercises • Transfer training • Progressive gait training • PROM: Flexion (prone and standing) • AAROM: Flexion (seated) • AROM: SLR, Heel raises, leg curls • Joint mobilization
  34. Home health (Phase IIb ) • 2-3 weeks Goal : Safe and independent in home setting Independent Ambulation using appropriate assistive device Community mobilization ROM 0-110
  35. • Home safety and adjustments • Gait training and transfer in uneven surface • Continuation of previous knee ROM and strength • Progressive weight bearing
  36. Weaning of assistive devices • 6 weeks • Walker to 4 point cane to 1 point cane • Independent mobilization and unassisted gait training
  37. Out patient • 3-12 weeks • Normalise gait pattern and reduce reliance on assistive device • Increase ROM > 125 • Single leg half squat 65% of body weight • Full weight bearing with single stance • Step up Step down by 6 weeks
  38. • Continuation of ROM stretches • Squats, leg press, bridging • Hip ER exercises • Aerobic conditioning and weight reduction • Balance and proprioception exercises • Return to previous activities
  39. Return to activity • Activity that maintain cardiovascular fitness while subjecting implant to least impact loading stresses – Treadmill walking, stair climbing, stationary bicycle • Acceptable Outdoor activities – Golfing, hiking, cycling, swimming, occasional doubles tennis • Discouraged Activities – Running, Football, Volleyball, martial arts
  40. • Life long Lifestyle modification including avoidance of cross legged sitting, kneeling • Quadricep strengthening should be practiced for longevity of prosthesis and improvement in ADL
  41. Conclusion • Arthroplasty is one of the successful orthopedic procedure giving best outcome to the patient • Not a Surgery to bedrest rather to mobilise from the earliest • Role of preoperative and post operative physical therapy have their share of role in best outcome • The ultimate goal is to make the patient have pain free joint with maximal function
  42. References • Rehabilitation for post surgical orthopedics patient, 3e • Therapeutic Exercises Foundations and Technique 7e
  43. Next Presentation Periprosthetic Joint Infection and Fractures by Dr Kisan Nepali

Editor's Notes

  1. THR virtually relieves pain and improves the function of all severly arthritis hip joint and disabled patients One of the successful orthopedic procedures but the success relies not only on the placement of implant but on the appropriate physical therapy following the procedure to improve the function
  2. Pre op Diagnosis : AS/ RA Comorbidities : Cardiovascular, medical comorbidities, affecting the medical fitness of patient
  3. Set Patients expectations towards the early independence and wellness Individualise the process, Boost confidence, reduces the length of hospital stay Preop Session : Vitals of patient and level endurance, safety awareness, Locally Edema, contractures, LLD Stair, hallway, Sidewalks.
  4. To improve the ventilation perfusion ratio
  5. aseptic loosening (36.5%) infection (15.3%) Cerebral palsy, Muscular dystrophy Parkinsonism, Dementia Sarcopenia, Loss of proprioception ,increased risk of fall, fall in elderly Dislocation promoting movements : Deep flexion or IR
  6. Hyperlaxity of the joint due to muscular insufficiency or lack of soft-tissue tension. Proper post op sleeping and sitting techniques Patient may be able to recite the points but may be inadverently moving the joint in irregular fashion which can lead to dislocation
  7. Hemodynamically stable with no features of excessive pain or postural hypotension Complication : thromboembolic, pulmoanry Hygeine, Repositioning patient every 2 hours to prevent bedsores,
  8. Avoid Ankle circle and rotation. Patient may inadverently perform IR of hip. Always ask patient to point toe to the sky Transfer training : supine to sitting, sitting to standing (sitting as tolerated 30-60 min ) Use of upper extremity in the transfer of body rather than pivoting on the operated leg No excessive pain, no fatigue and dizziness. Day 2 Heel slides ,
  9. Customary to limit weight bearing after cementless THR as it is assumed that early excessive loading may cause micromovement preventing the osseous ingrowth and loosen the implant
  10. No features of infection, medically fit and good tolerance to inpatient program
  11. Resisted Hip abductor strengthening with theraband Open chain :Heel raise and Mini squats
  12. Old mishappen shoes : Pain and abnormal gait pattern shoes may adapt to abnormal stresses LLD : post surgical
  13. Sidestepping : functional Abductor exercises stimulating both gluteus and hip ER
  14. SL Single leg
  15. Shortened step length of uninvolved lower extremity Increased flexion at the waist during mid to late stance Antalgic gait Feeling of leg length inequality during gait due to abductor contracture Trendelenburg (contralateral pelvic drop) trunk lean toward affected limb in stance
  16. 2007 Consensus guideline on return to athletic activities by the Hip Society and American Association of Hip and Knee surgeons
  17. he Don'ts Don't cross your legs at the knees for at least 6 to 8 weeks. Don't bring your knee up higher than your hip. Don't lean forward while sitting or as you sit down. Don't try to pick up something on the floor while you are sitting. Don't turn your feet excessively inward or outward when you bend down. Don't reach down to pull up blankets when lying in bed. Don't bend at the waist beyond 90 degrees. The Dos Do keep the leg facing forward. Do keep the affected leg in front as you sit or stand. Do kneel on the knee on the operated leg (the bad side). Do cut back on your exercises if your muscles begin to ache, but don't stop doing them.
  18. Patient edcuation regarding the disease and disease process and progression Prescription of high and low resistance training exercises from the conservative course of treatment for OA Knee. Goal to prevent the surgery History and examination of the patient to evaluate the joint alignment, stability, ROM, Muscle tone and limb length
  19. Boost confidence, anticipated course and progression of treatment Formulate holistic goals and expectations Home planning, social planning
  20. IV Antibiotics for infection along with analgesics DVT prophylaxis and Ankle pumps Chest Physio and incentive spirometry : breathing exercises promotes full excursion of rib cage
  21. Leg straight with pillow positioned beneath ankle to increase end range extension and venous drainage and decreased compression of posterior tibial vein Brace Early ROM : Improvement of wound healing, accelerated clearance of hemarthosis, reduced muscle atrophy, adhesions, less risk of DVT and decreased hospital stay and need for pain medication
  22. Preoperative requirement
  23. Seated heel slides Assisted flexion and passive extensions SLR and Terminal Knee extensions strengthen Quadriceps and hence improve dynamic stabilisers of knee Prepare extensor mechanism to bear weight Prepare for home disposition and independent mobilization
  24. General condition Pain intensity Fever On oxygen therapy Hb : Requiring transfusion Postural hypotension Post operative delirium
  25. Physiotherapy stand point With No significant feature of infection or increase in pain, the patient can be discharged from acute care and managed under extended care
  26. With No significant feature of infection or increase in pain, the patient can be discharged from acute care and managed under extended care
  27. Stair climbing 110
  28. Prevents the unprecendent complication of falling Return to independent living Strengthen the lower kinetic chain Stair climbing/ sitting in a normal toilet of height 17 inch/ stationary bike riding: 110 Post Op contracture prevention
  29. Full quadricep strength is necessary to noramlise gait pattern, and to facilitate the quad strength
  30. As obesity increase the wear and tear on the implant Swimming, distance walking and stationary bicycling : Non Impact activities Prioprioception, balance and postural control activities according to age
  31. Joint forces at tibiofemoral interface walking 1.2-4 times PFJ 0.5 1.2 times on stationary cycling 2-8 times while running PFH 3.4
  32. Longevity of prosthesis and ADL improves
  33. Releiving pain and disability
  34. Lisa maxey, Jim Magnusson Carolyn Kishner