subjective

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Done By:

When Surgery Is Recommended ?

reference:

http://www.sanchetihospitalspecialisedsurgeries.com/

Post-operative complications may include:

1. Infection

2. Stiffness

3. Blood clots

4. Loosening of the prosthesis

5. Prosthetic breakage and dislocated

6. Injury to nerves or blood vessels

Case scenario

Total Knee replacement

Total Knee

replacement

Subjective

Chief complain : sever Pain in Lt knee.

Present History : pain start 3 year ago in both knee and gradually increas and dignosed with OA .The doctor dicide to TKR for the right knee 1 years ago and now they will do the lift knee .

Px name:Fahima Bayoumi.

Age : 65 .

Sex : Female.

Nationality : Egyptian.

M.status: Married.

Occupation : House wife.

Ref.Dept : OPD.

Date : 25-11-2015.

Diagnosis :OA –Generaliz,un specific.

- VAS : 8/10.

- Exaggerating factors :long standing, at night

- Relieving factors : sitting and rising the leg

- Past History :hypothyroidism

- Medication: Analgestic, cream for pain, medication for hypothyroidism

Proprioception

• Single leg stance

• Static balance.

- Continue with phase 2 exercises adding and increasing resistance as tolerated

- Add resistance machines as appropriate including leg press, hamstring curl, and 4-way hipmachine

Balance on wobble

board

Tandem walk

Recommended Exercises

agility exercises:

side step

Endurance

Joint Mobilizations

ROM & flexibility

- Continue with phase 2 activities

Walking program

Biking program

Phase

Intermediate Phase (6-12 Weeks)

Leg press

- Continue ROM exercises from phase 1 and 2

- Continue biking, adding mild to moderate resistance .

Hamstring curl

Guidelines :

Recommended Exercises

Perform ROM and flexibility exercises daily.

Perform strengthening and proprioception exercises 3-5x/ week, performing 2-3 sets of 10-15repetitions.

Continue endurance program 30-45 minutes 3x/ week.

Phase

Precautions :

- Avoid high impact, and contact sports

- Avoid repetitive heavy lifting

Advanced Phase (12 Weeks and Beyond)

ROM and Flexibility:

Continue daily ROM and stretching exercises

Strengthening:

Continue with all strengthening exercises increasing resistance and decreasing repetitions

Proprioception:

Continue with all phase 3 exercises, increasing difficulty as tolerated.

Endurance:

Continue with walking, biking, elliptical machine programs

Guidelines

Goals:

ROM and stretching exercises once a day until normal ROM is achieved.

Hold stretches for 30 seconds and perform 2-3 repetitions of each.

strengthening exercises 3-5 times a week. Do 2-3 sets of 15-20 Reps.

ROM Bike at least 10 minutes daily if able.

Progress to biking/walking for at 20-30 minutes 3x/week for endurance

- Continue to improve strength to maximize functional outcomes

- Return to appropriate recreational activities (i.e. golf, doubles tennis, cycling)

Precautions :

• Avoid high impact activities

• Avoid activities that require repeated pivoting/twisting

Precautions

WBAT with crutches or walker, progressing to cane.

Monitor for proper wound healing .

Monitor for signs of infection .

Monitor for increased oedema .

AROM

0-110 degree

Good voluntary quadriceps control

Criteria for progression to the next phase

Therapeutic exercise and functional exercise

5. CKC exercises( terminal knee extension,

mini squat)

6. Use sit to stand and chair exercises

1. Continue with all phase 1 ROM and mobilization exercises.

2. ROM exercises: heel slide with towel , prone knee flexion and heel prop

7. Begin pool program if incision is completely healed

9. propriceptive Exercise: single leg stand

3. Initiate stationary biking.

4. Initiate hamstring, calf and

quadriceps muscles stretching.

Guidelines :

- Perform 10-20repetitions 3 times/day.

- Hold stretches for 30 seconds and perform 2-3 repetitions of each.

- Bike daily for 5-10 minutes if able.

Functional training and Modalities:

- As previous.

ideal treatment

Phase

motion phase(Day3-week6)

Circumferential measurements:

Goals of physical therapy intervention :

Continue to improve ROM with a goal of more than110 degrees

Begin to restore muscle strength specially on the Quadriceps

Initiate endurance and proprioceptivetraining.

Normalize all functional mobility.

Normal gait pattern.

- Gait: Normal

- ADL Assesment : Normal

Palpation :

Objective

- Temperature: Normal

- Tenderness : Yes, in medial aspect of Lt knee

- Degree: Sever

- Spasm: No

"Inspection"

Ability to do Quadriceps contraction

Independent transfers and ambulation at least 100 feet

Active knee ROM

(10°-80°)

Criteria for progression to the next phase

Minimal pain and inflammation

Precautions

• WBAT with crutches or walker

unless otherwise ordered

• Screen for sensory/motor deficits
• Screen for DVT
• No resistance exercises.
• Avoid twisting forces across the knee joint .

Positioning

in bed

• Use a towel roll under ankle to promote knee extension Positioning.
• Use a trochanter roll to maintain hip in neutral rotation and promote knee extension.
• Never place anything under the operated knee

Therapeutic exercise and functional exercise

1. Use Continuous Passive Motion (CPM)

2. Active\active assisted\passive

exercise from supine and sitting.

- ankle pump

Guidelines :

Perform 10 repetitions of

all exercises 3-5 times a day

Phase

immediate post surgical phase

(0-3Days)

Goals of physical therapy intervention :

- PT Diagnosis: Advanced osteoarthritis

- Short Term Goals:

1. To decrease pain.

2. To improve ROM

3.To improve muscle power.

- Long Term Goals:

To return the patient to the normal ADL without pain.

Assessment

Home instruction:

to do the same exercise

Plan of Treatment

1. Ankle pumps : 10rep

2. Straight leg raising SLR : 5s hold 10 rep

3. Terminal Knee extension: 10 rep

4. Quadriceps sets: 10 rep

5. Hip rotation exercise: 10 rep

6. Heel pres: 10 rep

7. heel slide: 10 rep

8. AROM exercise for hip (Abduction, Adduction): 10rep

PT diagnosis: left total knee replacement

Problem list:

1- pain & swelling in Lt knee

2- Limited ROM in Lt knee (extension & flexion)

3- Muscle weakness (Lt knee flexors & extensors).

4- Muscle tightness (Lt hamstring)

5- walking difficulty.

PT Management

Home instruction

1. Circulatory exercise: ankle pump

- Quadriceps set ( 10 rep, 10 sec hold)

- Use assistive gait device to prevent falling .

- Avoid knee flexion over 90 degree.

- Hamstrings set ( 10 rep, 10 sec hold)

repeat the previous exercises, try to do a hamstrings stretch (toe reach).

Elevate your leg , while sleeping.

Take care of the wound state.

Put on colds packs if pain exacerbate.

Recommendation of taking out patient physical therapy session.

3. Gait training exercise.

4. ROM exercise.

Chief complain: sever Pain in Lt knee.

Present History: pain started 3 years ago in both knee and gradually increase and diagnosed with OA ,the Doctor decide to TKR for the Rt knee 1 year ago. TKR in the Lt knee .

VAS : 8/10.

Exaggerating factors: at night

Relieving factors: moving the ankle

Past History: hypothyroidism

Medication: analgesic ,cream for pain and medication for hypothyroidism.

subjective

Objec

tive

Px name: Fahima Bayoumi

Age: 65.

Sex: Female.

Nationality: Egyptian.

M.status: Married.

Occupation: House wife.

Ref.Dept : OPD.

Date: 2-12-2015.

Diagnosis: TKR in the left knee

Inspection:

General :

1. Level of consciousness: NL

2. Facial expression: Normal

3. Body Type : Endomorph

4. Body position: Normal

5. Ambulatory status : Normal

Local:

1. Color : Mild bluish

2. Swelling :large +ve in LT knee and we cannot touch it in medial aspect.