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Total Knee Replacement Protocol

Existing Protocols

Aims

Anthony Dixon

The aims of this presentation are:

  • Current evidence for rehabilitating TKR

  • Pre-surgical education

  • Existing protocols

  • Key principles of TKR rehabilitation protocols

  • Adapted protocol

Hartlepool and North Tees-

Both follow a protocol designed by the Royal National Orthopaedic Hospital.

Includes-

  • Pre-surgical education
  • Goals
  • Outlines restrictions at each stage of rehab
  • Variety of manual techniques to aid rehabilitation

University of Wisconsin Hospital and Clinics-

Designed a protocol with emphasis on ROM, strength and functional status.

No mention of functional

exercises other than STS.

Unsure of emphasis placed

on patient centred goals.

Key principles of rehab

Evidence Based research

CONCLUSION

Topics of research include- ROM, strength, balance and function.

Range of Motion-

The first 3 weeks after surgery are the most important to prevent the development of scar tissue within the knee joint. Active and passive stretches are the best ways to avoid long term complications with your joint replacement (4)

Strength-

Lower extremity

strength has a major

role in knee joint shock absorption during weight bearing activities, particularly the quadriceps (5)

Evidence

According to NICE guidelines a patient should be considered for TKR or UKR surgery if they have moderate to severe knee pain which is not managed adequately.

Topics covered in research- types of exercises, home exercises programme vs supervised physiotherapy programme, pre-surgical education, progressive resistance exercises and balance strategies.

  • No difference was found between the patients performing supervised or standardized home program with respect to the effects on functional status. Home exercises help reduce health care spending (1)

  • Artz et al., (2015) (2) states that physiotherapy exercise provided at home are an appealing approach with the possibility of wider acceptability and uptake.

Background

Key principles of rehab

Pre-surgical education/strength

  • Evidence seems to be clear regarding the basics of TKR rehabilitation.

  • But there seems to be little emphasis on patients expectations/goals within the protocols

  • Other NHS protcols do not seem to focus on functional activities/outcomes.

Better Quality of Life!

  • Hence the importance of patient centred goals and focus on function rather than solely on objective measures.

Balance/proprioception

Specialised training exercises help your muscles "learn" to respond to changes in your world, such as uneven or rocky ground.

Several studies have suggested that an effective way to improve physical performance is to focus on a combination of balance/proprioception and functional exercises (6,7)

Function

The goal of knee replacement surgery is to return you to normal functional activities as soon as possible (4)

Patients’ expectations after joint replacement seem to be quantified simply: no pain and free function (8)

Rehabilitation doesn't start after surgery, it starts before!

American Physical Therapist Association (3)-

• The better physical shape you are in before TKR surgery, the better your results will be (especially in the short term).

• One of the major benefits SRH has is the knee school which patients attend before surgery.

Strength-

  • Upcoming RCT's evaulating the effect of additional strength training, independant exercise prescription compared to supervised exercises and progressive resistance training compared to traditional resistance training (2)

Adapted Protocol

Focus of Protocol

The focus of this protocol was to provide optimum post operative rehabilitation to each TKR patient.

Key principle throughout the process was to remain patient centred and remain consicous of the practitioner/patients goals.

Early achievement of patient full potential ROM, strength and regaining previous mobility level was seen as the initial goals.

As the rehabilitation process continues goals shift towards more weight bearing/functional activities.

Week 1-6

Goals

  • At 6 weeks full extension (may take longer depending of patient history)
  • Increasing flexion (depending on type of joint replacement)
  • To wean from walking aids as comfort, swelling and knee control allows, with normal gait
  • To be independent with a HEP

Exercises

  • Knee ROM
  • Strength exercises- quads- static quads, IRQS and SLR

(9, 10)

  • Hamstrings. Glutes- weight bearing activities
  • Balance/proprioception- single leg stand progressing to

an unstable surface

  • Backwards walking (11)
  • Functional rehabilitation- STS, step ups etc. Using

functional outcome measures to assess progress

throughout treatment e.g. Timed up and go (12)

Week 6 onwards

Goals

  • Full extension and flexion
  • Able to perform all ADL’s
  • Independent mobility unaided
  • Reintroduction of sporting activities
  • Reiterate restrictions on long distance running,

heavy manual labour, high impact or agility

sports such as football, tennis etc.

Exercises

  • Increasing fitness in relation to functional/sporting activites e.g. static bike, treadmill, X-trainer, step ups, mini squats
  • Dynamic and rhythmic stabilisation exercises
  • Strengthening throughout range
  • Continued stretching of tight structures
  • Progression of balance/proprioception utilising different surfaces and introducing gym ball, trampets and wobble boards
  • Hydrotherapy if appropriate
  • Return to work
  • Reference to functional outcome measures and patient goals

Thank You!

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