Rehabilitation following THR and TKR.pptx

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 v s 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 1 st and 2 nd 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 i ntensity 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 s trengthening 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, h amstring 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 p hysio 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 Post operative delirium

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