A Leg Up: Aggressive Treatments Spur TKA Recovery
Monday August 16, 2010
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As total knee arthroplasty becomes increasingly common, physical therapists are compelled to determine the best practices for rehabilitation. Although surgery usually mitigates the pain patients have been living with for years, freedom from pain alone does not translate to improved, lasting functionality.
“I am passionate about rehabilitation after a total knee replacement,” says Lynn Snyder-Mackler, PT, ATC, ScD, SCS, FAPTA, a professor in the physical therapy department at the University of Delaware. “I’d love to see people be able to be more active than they are currently after TKA and have their knee replacements last longer.”
The demand for total knee replacement in the U.S. is already high, with about 500,000 TKA procedures performed annually, but that number is expected to grow exponentially in the next two decades to 3.4 million per year by 2030, according to research presented at the 2006 meeting of the American Academy of Orthopaedic Surgeons.
Like Snyder-Mackler, Orlando Ruiz, DPT, MBA, head of physical therapy for the total joint program at North Broward Medical Center in Florida, had a desire to help patients become more active after surgery. This led him to experiment with a new rehab technique that has proven to be highly successful with patients at his facility.
He observed that the femoral nerve block patients received before surgery often would weaken the quadriceps muscle for several days. “Patients couldn’t do enough soon enough,” he says. “And when they were ready to start walking, the knee was more likely to buckle and this increased the risk of falling.”
He asks patients to sit upright in a chair and place one foot on the ground and the other on a skateboard. The skateboard rolls as patients stretch the knee to the point that their toes are pointing to the ceiling, and then they roll the skateboard back as far as they can to bend the knee. He does this as part of PT exercises two times a day. This technique engages the hamstring muscles to allow him to work on flexion of the knee. The patient also benefits from bearing the weight of the leg on the skateboard.
“It doesn’t make the quadriceps come back sooner, but the range of motion is better and it helps [patients] psychologically because they are actively participating in an exercise,” he says. As a result, patients are walking with an assistive device roughly one day sooner, and they are more motivated to continue rehabilitation because they see progress.
Another strategy that appears to improve outcomes is starting PT before surgery if possible, says Jeffrey Wright, PT, ATC, CSCS, director of rehabilitative services at Providence Hospital in Washington, D.C., author of a January 2010 article in eMedicine.
If PTs can start a strengthening program for the upper and lower body before surgery, this speeds recovery, he says. “If someone is weak in the chest and shoulder muscles before surgery, they won’t be able to maneuver their body after TKA,” he says. “If you can do strengthening beforehand, they will have more ability to transfer from a wheelchair to a regular chair or from a bed to a chair. The outcomes are better in general if you can start strengthening earlier.”
Although most healthcare providers agree that physical therapy in the inpatient setting is necessary immediately following TKA, not all concur on the importance of rehab once the patient leaves the hospital. “Surgeons tend to think that if they improve knee flexion range of motion and reduce pain, then there is no need for rehab. But those two criteria don’t predict how people function in the long term,” Snyder-Mackler says.
Snyder-Mackler has found that strength of the quadriceps is strongly correlated to function, but conventional rehabilitation does not help patients strengthen this muscle sufficiently.
“The usual care for outpatients are things like leg lifts and riding a bicycle, but we have found that if you use progressive strengthening for one to three months after TKA, it results in far better outcomes,” she says.
Even when the knee pain improves after surgery, studies have shown that patients return only to the same level of activity they had before surgery — rather than returning to the activities they enjoyed before having severe knee pain.
“What we are finding is that even in the most aggressive post-op programs, the strength gains don’t exceed the strength that patients had before surgery,” says Tara Jo Manal, PT, DPT, OCS, SCS, an associate professor at the University of Delaware.
To help patients exceed their pre-op activity level, PTs can encourage patients to use daily activities as an opportunity to perform strengthening exercises. “For each step, they can tighten the thigh, pull the kneecap up, extend the knee and transfer the weight through the limb,” Manal says.
Electrical stimulation can assist with muscle reactivation, and the earlier the better, Manal says. If electrical stimulation is used for patients at all, it usually begins at week four after surgery, but new research suggests that sooner is better. “Researchers are in the process of finding that starting electrical stimulation as early as day two after surgery may improve post-op function,” Manal says.
Whether in the inpatient or outpatient setting, PTs like Manal are seeking ways to help patients exceed the current expectations for functionality after TKA. “We are debunking the myth that aggressive exercise after total knee will delay recovery,” Manal says. “It is an unfounded fear. I believe this may lead to an acute- and home-care revolution.” •
Heather Stringer is a freelance writer.
“I am passionate about rehabilitation after a total knee replacement,” says Lynn Snyder-Mackler, PT, ATC, ScD, SCS, FAPTA, a professor in the physical therapy department at the University of Delaware. “I’d love to see people be able to be more active than they are currently after TKA and have their knee replacements last longer.”
The demand for total knee replacement in the U.S. is already high, with about 500,000 TKA procedures performed annually, but that number is expected to grow exponentially in the next two decades to 3.4 million per year by 2030, according to research presented at the 2006 meeting of the American Academy of Orthopaedic Surgeons.
Like Snyder-Mackler, Orlando Ruiz, DPT, MBA, head of physical therapy for the total joint program at North Broward Medical Center in Florida, had a desire to help patients become more active after surgery. This led him to experiment with a new rehab technique that has proven to be highly successful with patients at his facility.
He observed that the femoral nerve block patients received before surgery often would weaken the quadriceps muscle for several days. “Patients couldn’t do enough soon enough,” he says. “And when they were ready to start walking, the knee was more likely to buckle and this increased the risk of falling.”
He asks patients to sit upright in a chair and place one foot on the ground and the other on a skateboard. The skateboard rolls as patients stretch the knee to the point that their toes are pointing to the ceiling, and then they roll the skateboard back as far as they can to bend the knee. He does this as part of PT exercises two times a day. This technique engages the hamstring muscles to allow him to work on flexion of the knee. The patient also benefits from bearing the weight of the leg on the skateboard.
“It doesn’t make the quadriceps come back sooner, but the range of motion is better and it helps [patients] psychologically because they are actively participating in an exercise,” he says. As a result, patients are walking with an assistive device roughly one day sooner, and they are more motivated to continue rehabilitation because they see progress.
Another strategy that appears to improve outcomes is starting PT before surgery if possible, says Jeffrey Wright, PT, ATC, CSCS, director of rehabilitative services at Providence Hospital in Washington, D.C., author of a January 2010 article in eMedicine.
If PTs can start a strengthening program for the upper and lower body before surgery, this speeds recovery, he says. “If someone is weak in the chest and shoulder muscles before surgery, they won’t be able to maneuver their body after TKA,” he says. “If you can do strengthening beforehand, they will have more ability to transfer from a wheelchair to a regular chair or from a bed to a chair. The outcomes are better in general if you can start strengthening earlier.”
Although most healthcare providers agree that physical therapy in the inpatient setting is necessary immediately following TKA, not all concur on the importance of rehab once the patient leaves the hospital. “Surgeons tend to think that if they improve knee flexion range of motion and reduce pain, then there is no need for rehab. But those two criteria don’t predict how people function in the long term,” Snyder-Mackler says.
Snyder-Mackler has found that strength of the quadriceps is strongly correlated to function, but conventional rehabilitation does not help patients strengthen this muscle sufficiently.
“The usual care for outpatients are things like leg lifts and riding a bicycle, but we have found that if you use progressive strengthening for one to three months after TKA, it results in far better outcomes,” she says.
Even when the knee pain improves after surgery, studies have shown that patients return only to the same level of activity they had before surgery — rather than returning to the activities they enjoyed before having severe knee pain.
“What we are finding is that even in the most aggressive post-op programs, the strength gains don’t exceed the strength that patients had before surgery,” says Tara Jo Manal, PT, DPT, OCS, SCS, an associate professor at the University of Delaware.
To help patients exceed their pre-op activity level, PTs can encourage patients to use daily activities as an opportunity to perform strengthening exercises. “For each step, they can tighten the thigh, pull the kneecap up, extend the knee and transfer the weight through the limb,” Manal says.
Electrical stimulation can assist with muscle reactivation, and the earlier the better, Manal says. If electrical stimulation is used for patients at all, it usually begins at week four after surgery, but new research suggests that sooner is better. “Researchers are in the process of finding that starting electrical stimulation as early as day two after surgery may improve post-op function,” Manal says.
Whether in the inpatient or outpatient setting, PTs like Manal are seeking ways to help patients exceed the current expectations for functionality after TKA. “We are debunking the myth that aggressive exercise after total knee will delay recovery,” Manal says. “It is an unfounded fear. I believe this may lead to an acute- and home-care revolution.” •
Heather Stringer is a freelance writer.
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Monday August 16, 2010