The commonly practiced prehabiliation and post operative rehabilitation following Total Hip and Total Knee replacement/Arthtoplasty.

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

17. 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

18. • 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

19. • Shoe adaptation
• Progression from 4 wheeled walker to single
cane (3-4 weeks )
• Non weight bearing > PWBM > FWB with
crutches
• Unsupported Gait training

20. After 3 months
• Open Chain and Closed Kinetic exercises
• Sidestepping exercise
• Modified Lunges
• Aerobic conditioning
• Step over step stair climbing

21. 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

22. OPD clinics
• Physically Demanding patients
– Additional strength and endurance training
• Not fulfilling Home based therapy
Requirements
– Lingering gait
• Weight shifting
• Hip strengthening exercises

23. Athletic Activities following THR

24. The DONTS following THR

25. Total Knee Replacement

26. 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

27. • Familiarization with surgical procedures and
phases of rehabilitation
• Quads strengthening/ Hamstring Stretching
• Patellar mobilization
• FFD : Posterior capsule, hamstring and calf
stretching

28. Inpatient acute care
• Time 1-5 days after surgery
• Goal :
– Prevent complication
– Reduce pain and swelling
– Promote ROM
– Restore safety and independence

29. • Position
• AROM : ankle pump,
circumduction
• PROM : knee extension
and flexion, supine heel
slide
• Isometric: quad,
hamstring, gluteal sets

30. • Chest physio and incentive spirometry
• Transfer and bed mobility trainings

31. Day 2 :
• A/AROM :
• AROM with heel slides in
supine and sitting position
• Terminal knee extensions
• SLR

32. 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

33. Discharge Criteria
• Patient able to demonstrate 80-90 degree of
motion
• Transfer supine to sitting, sitting to standing
independently
• Ambulate 15-100 feet

34. 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

35. • 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

36. 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

37. • Home safety and adjustments
• Gait training and transfer in uneven surface
• Continuation of previous knee ROM and
strength
• Progressive weight bearing

38. Weaning of assistive devices
• 6 weeks
• Walker to 4 point cane to 1 point cane
• Independent mobilization and unassisted gait
training

39. 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

40. • Continuation of ROM stretches
• Squats, leg press, bridging
• Hip ER exercises
• Aerobic conditioning and weight reduction
• Balance and proprioception exercises
• Return to previous activities

41. 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

42. • Life long Lifestyle modification including
avoidance of cross legged sitting, kneeling
• Quadricep strengthening should be practiced
for longevity of prosthesis and improvement
in ADL

43. 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

44. References
• Rehabilitation for post surgical orthopedics
patient, 3e
• Therapeutic Exercises Foundations and
Technique 7e

45. Next Presentation
Periprosthetic Joint Infection and Fractures by
Dr Kisan Nepali