COMPS:PT Mgmt of Pts w/ Hip and Knee OA--ZENI Flashcards
(128 cards)
1
Q
OA is a ________ process
*NOT just wear and tear
A
Disease process
2
Q
Defining Knee OA radiographs
Kellgren Lawrence Scores*
4 Grades
A
Graded 0 (none)
to
Grade 4 (severe)
3
Q
Defining Knee OA
Kellgren-Lawrence Scores
Grade 0 (NONE)
A
- Grade 0== NONE
- definite absence of x-ray changes of OA
4
Q
Defining Knee OA
Kellgren Lawrence scores
Grade 1 (Doubtful)
A
- Grade 1 == doubtful
- doubtful jt space narrowing and possible osteophytic lipping
5
Q
Defining knee OA
Kellgren Lawrence Scores
Grade 2 (minimal)
A
- Grade 2== minimal
- definite osteophytes and possible jt space narrowing
6
Q
Defining Knee OA
Kellgren Lawrence Scores
Grade 3 (Moderate)
A
- Grade 3== moderate
- moderate multiple osteophytes, definite narrowing of jt space and some sclerosis and possible deformity of bone ends
7
Q
Defining Knee OA
Kellgren Lawrence Scores
Grade 4 (severe)
A
- Grade 4== severe
- Large osteophytes, marked narrowing of jt space, severe sclerosis and definite deformity of bone ends
8
Q
Uni or Multi-compartmental disease @ the Knee
A
- Medial
- Lateral
- Patellofem
SEE pics !!!
9
Q
Advanced OA Knee
A
see pics
10
Q
Defining Knee OA–Clinical Presentation
The Cardinal Signs
A
Age
Brief AM stiffness
Crepitus
Tenderness
Bony abnorms
NO warmth
11
Q
Defining Knee OA–clinical present.
ACR Clinical definition
PAIN IN THE KNEE PLUS @ least 3 of the following:
A
- Pain in the knee + 3 of following:
- >50yo
- <30 mins morning stiff.
- crepitus w/ active motion
- bony tenderness
- bony enlargement
- NO palpable warmth of synovium
NOTE: some studies show that these criteria reflect later stage disease and may not capture indiv’s w/ EARLY or MILD OA****
12
Q
2 scales common in grading HIP OA
A
- KL Scale
- Tönnis Classification
see below for Tönnis
13
Q
In a nutshell….. Tönnis Scale of HIP OA
A
- 0
- NONE
- 1
- mild
- minor
- No or minor
- 2
- moderate
- moderate
- moderate
- 3
- Severe
- Severe
- Severe
14
Q
Defining HIP OA—clinical present:
Very high likelihood of Hip OA w/ 4 out of these 5 present:
A
- Self-reported squatting as an aggravating factor
- Active hip flexion causing LATERAL hip pain
- Scour test w/ ADD. causing lateral hip OR groin pain
- Active hip EXT causing pain
- passive IR of LESS THAN or EQUAL to 25deg
15
Q
OA is more than just cartilage loss
Jt swelling, bursa inflammation, changes to synovial fluid and jt capsule
A
see pics
16
Q
OA is more than just cartilage loss
Mm atrophy, weakness, morphological changes
ex. fat permeating into jt
A
see pics
17
Q
OA more than just cartilage loss
Cartilage deterioration (X-ray) and Morphological changes (MRI)
A
see pics
18
Q
OA more than just cartilage loss
Osteophytes, thickening of subchondral bone, Bone Marrow lesions (MRI)
A
see pics
19
Q
OA cannot _________
A
CANNOT be considered a disease of ONLY the articular cartilage!!!
20
Q
Activation Deficit
Prominantly in OA
A
- Diff AFTER electrical stim vs. what pt can do volitionally
- neurological system cannot fullt activate ALL mm’s in a region
**Quadriceps Lag**
21
Q
Mvmt patterns and motor control also change
Asymmetrical and abnorm biomechanics
Favoring the Good side
For Knee…
A
Stiff legged gait pattern
CARDINAL SIGN
22
Q
Mvmt patterns and motor control also change
Asymmetrical and abnorm biomechanics
Favoring the Good side
The Hip….
A
Lateral and forward trunk lean TOWARD GOOD SIDE
DECd hip EXT ROM
23
Q
CARDINAL SIGN HIP OA
A
Lat. trunk lean w/ walking TOWARDS AFFECTED SIDE
24
Q
Mvmt patterns and motor control changes
Knee OA
co-contraction vs. muscle timing
A
INC’D co-contraction
ALTERED mm timing
25
Alignment changes, Jt Load changes
## Footnote
**Knee OA**
**What is the pattern?**
Malalignment==\> Altered Loading==\>Cartilage Loss==\>Malalignment
26
Valgus vs. Neutral vs. Varus Radiographs
* **More cartilage loss==**
* ****worse alignment becomes
* **Worse alignment becomes==**
* ****more abnormal forces become
* **More abnormal forces become==**
* ****more cartilage is lost
27
Phys. impairments lead to \_\_\_\_\_\_\_\_\_
Functional Deficits
* Ex. OA vs. Control group
* TESTED:
* Age
* KOS-ADLS
* TUG
* SCT
* Quad Strength (Op)
* **Nearly 50% reduction in KOS, TUG, SCT and Quad strength**
28
In a nutshell....
**The Cycle**
**Injury (ACL, fx), Bony deformity, Weakness, Unfortunate genetics ======\>**
* Joint pain==\> Decd phys act==\> muscle weakness==\> abnormal biomechanics==\> cartilage loss and jt laxity==\> Joint pain
* **Over the span of 5-20 yrs**
* **Drs usually say**
* **"come back when nothing else works and you can't take pain anymore"**
29
**Primary OA**
**\*usually older pop.**
* Disease is of **idiopathic origin (no known cause)**
* Usually affects **mult. joints**
* **Elderly pop**
30
**Secondary OA**
**\*monoarticular**
* **Monoarticular**
* develops as result of **defined disorder** affecting **jt articular surface (ex. trauma)** or from **abnormalities of joint**
31
Secondary OA
## Footnote
**Hip**
* Dysplasia
* SCFE
* Fx
* FAI
* Avascular necrosis
32
Secondary OA
**Knee**
* Trauma
* **chondral lesions**
* ACL injury
* Fx's
33
Radiographic DOES NOT always match sx's
## Footnote
**Do NOT emphasize structure**
**Emphasize Function!!**
* DO NOT SAY:
* **Bone-on-bone**
* **end-stage**
34
Certain descriptors of OA make pts feel:
* Jt is susceptible to damage
* OA will inevitably get WORSE
* TKA is only option and cond. is irreversible
* Doing more exercise or activity will damage the joint
## Footnote
**ALL WRONG!!!**
35
OA is a serious cond. and needs to **be approp. mg'd, NOT just put off until TKA**
INCd risk of **CV disorders, morbidity, mortality**
36
Key Points:
## Footnote
**OA Patho.**
* OA==more than just a disease of cartilage
* OA is a **chronic cond** and must be tx as such
* Pts. develop **asymmetrical mvmt patterns**
* **Reduce** demand on **operated limb** and **INC** reliance on the **non-affected side**
* Result of pain, weakness, laxity
* which came first???
* Pts w/ **hip and knee OA** develop behaviors **in response to PAIN**
37
Risk factors for OA development and progression
What are some ex's?
Phys activity and risk
ROM deficits
Muscle control deficits
Dynamic frontal plane alignment
38
Injury Type vs. Risk of Developing OA compared to an uninjured group
Basically.... based off of previous injury type, what is your risk (likelihood) of developing OA?
see pics
39
Phys activity and risk for **Knee OA**
## Footnote
**what factors INC risk for OA?**
* **Previous injury**
* ****see previous chart
40
Phys activity and risk for OA
## Footnote
**Not all meniscal injuries have same risk!**
* Medial extrusion, complex tears, large radial involvement **were more common in those who develop OA\*\*\***
41
Sports and risk for OA
## Footnote
**Sports are generally NOT a risk factor**
**Exceptions:**
* Soccer
* 3.5x INC risk
* Elite lvl long dist running
* 3.3x INC risk
* Competitive wt lifting
* 6.9x INC risk
* Wrestling
* 3.8x INC risk
* **For those w/out history of injury-- soccer and Am football had INCd risk of OA**
42
Vocation and risk for OA
* Kneeling or squatting
* 2-7x inc risk
* Heavy lifting
* 1.9-7.31x INC risk for **Knee**
* 2.46x INC risk for **Hip**
* ******Dose resp to freq of lifting OR total wt lifted**
* Heavy lifting + Kneeling or Squatting
* 2.4 **lifting alone,** 3.4 w/ **kneeling or squatting**
43
Risk Factors for Hip OA
**Modifiable**
**vs.**
**Structural or Congenital**
**see pics**
44
Recreational risk factors for Hip OA
## Footnote
**sports: Am football, track and field, racket sports**
may INC RISK
45
Rec. risk factors for Hip OA
## Footnote
**Freq stair climbing**
May INC RISK
46
Rec. risk factors for Hip OA
## Footnote
**Recreational running**
DOES NOT INC RISK
47
REC. risk factors for Hip OA
## Footnote
**Walking in lieu of running**
DOES NOT DECREASE RISK
48
REC. risk factors for Hip OA
## Footnote
**Leisure cycling or walking**
DOES NOT INCREASE RISK
49
GREATEST modifiable risk factor for OA ====
BMI
50
BMI
Greatest modifiable risk factor for OA
**sytemic inflammatory response also affecting joints**
* INCs risk for **hand, hip, knee OA**
* **Knee OA has greatest assoc w/ obesity**
* ****Overwt== 2x risk of healthy wt indiv.
* Grade 1 obesity== 3.1x risk
* Grade 2 obesity== 4.7x risk
51
BMI and OA
greatest modifiable risk factor
**Losing wt has protective bennies of OA**
* Losing **5% of bw** reduced risk of **knee OA progress. by 50% in women**
52
BMI
greatest modifiable risk factor for OA
**Wt. loss in pts w/ OA improves biomechanics \*\*\***
* Improvements in **gait** were NOT related to **improvements in pain**
53
Predictors of OA--Alignment
## Footnote
**Varus alignment**
4x INC in odds of **medial compartment OA progress.**
54
Predictors of OA--Alignment
## Footnote
**Valgus alignment**
5x INC in odds of **Lateral compartment OA progress.**
55
Predictors of OA--Alignment
## Footnote
**Higher BMI==STRONG risk factor for indiv's w/ Varus OR Valgus alignment\*\*\***
* BMI was NOT risk factor in **neutral align.**
* BMI WAS a risk in pts w/ **moderate varus or valgus**
56
Predictors of OA -- Thrust
## Footnote
**Varus or Valgus Thrust**
**explain..**
* quick mvmt in **frontal plane** during wt. bearing portion of gait cycle
* pt may have **normal static alignment**, but **lack of motor control** or **laxity in jt** leads to quick **varus or valgus thrust** during SLS
57
Predictors of OA--Thrust
* Varus or Valgus Thrust
* 4x inc in risk overall
* **3x INC in risk for pts w/ VARUS Alignment \*\*\*\*\***
58
Why is **alignment and thrust an issue?**
Changes magnitude and location of force
59
Adduction Moment @ the hip
* conceptualized as **distance b/w GRF vector and joint axis**
* ****Greater dist==greater moment
* Greater moment==greater loading
* **correlated to Medial Compart. jt loading**
* **\*\*predictive of Future OA progression\*\***
## Footnote
**M=FxD**
60
Adduction Moment
## Footnote
**How can we reduce the distance?**
* **Moving axis CLOSER to GRF**
* ****Unloader bracing
* Medial thrust modified gait
* **Moving GRF vector CLOSER to axis of the knee**
* ****Lateral trunk lean modified gait
* **Combo of the two**
* ****heel wedges
* Gait retraining
61
Biomechanics and knee OA
## Footnote
**more than just static alignment**
Small changes in **frontal plane** can influence OA incidence and progress.
62
Biomechanics and knee OA
**Biomech-based interventions should do what?**
* REDUCE abnorm frontal plane motion
* **stop the thrust**
* Put knee in NEUTRAL pos.
* **maintain alignment**
* Normalize shock-absorb feature of quads
* **no stiff-legged gait patterns**
* REDUCE overloading **med or lat comparts**
* ******reduce ADD moment**
63
Biomechanics and Knee OA
## Footnote
**addressing phys. impairments (ROM, weakness, proprio) shoud NOT exacerbate abnormal biomechanics**
**Don't make it worse!!!**
* Ex.
* **do NOT solely train ABD's in pt who is varus or has Varus Thrust**
64
Biomech. Screening for pts w/ OA
Includes what?
MSK Exam (strength, ROM, alignment, effusion, function)
Tools to assess **movement dysfunction**
65
MSK Assessment
* ROM
* **active/passive**
* Laxity
* Strength
* **Special tests for LE alignment**
66
Static and Dynamic Visual Movement Assess.
2 Components
1. **Static Postural/Alignment**
2. **Movement Assessment**
67
Static and Dynamic Visual Movement Assess.
## Footnote
**Static Postural/Alignment**
* Weight bearing
68
Static and Dynamic Visual Movement Assess
**Movement Assess**
* Recorded if poss. to slow down and stop video
* Try and pick **specific instances** of gait cycle AND specific joint, then REPEAT
* Gross abnorms
* Gross quality of mvmt
* Gross asymmetries
69
Static and Dynamic Visual Movement Assessment
see pics
Static postural/alignment
vs.
Movement assess.
70
Some ex's of Interventions for Pts w/ OA
Agility + Perturbation
Gait Retraining
Passive Devices
Monitoring response to tx
71
Interventions for OA
Address\_\_\_\_\_\_
Address\_\_\_\_\_\_
Address\_\_\_\_\_\_
Normalize\_\_\_\_\_
* Address phys impairments
* Address behavioral changes
* Address dynamic and static malalignment issues
* **Knee OA**
* Normalize biomechanics and reduce biomech. risks
72
Interventions for OA
## Footnote
**Addressing phys impairs**
weakness, ROM (jt contractures), instability
73
Interventions
**Addressing behavioral changes**
Encourage physical activity
\*\*6000 steps/day shoud be **target** to **reduce functional decline**
Weight loss
\*\*\***IDEA study--\> lose wt==less arthritis progress.**
74
Interventions
**Address dynamic and static malalignment issues in Knee OA**
Bracing
NMSK training
75
Interventions
## Footnote
**Normalize biomechanics and reduce biomech. risks**
Gait retrain.
Agility and ge. mvmt training
76
**STRONG evidence for all these interventions and Knee OA**
* exercise
* wt loss
* self-efficacy
* self-mgmt programs
* tai chi
* cane use
* tib/fib bracing for tib/fib knee OA
* NSAIDs for Knee OA---topical
* oral NSAIDs
* intraarticular glucocorticoid injections for knee OA
77
Knee OA interventions
## Footnote
**Conditional Use of these....**
* Balance ex
* yoga
* CBT (cognitive behavioral therapy)
* Patellofem. bracing for patellofem knee OA
* acupuncture
* thermal modals
* radiofreq. ablation for knee OA
78
Table: Recommendations for phsyical, psychosocial, and mind-body approaches for the mgmt of osteoarthritis
see pics
79
Knee strength and ADL training **VERSUS** Knee strength and ADL training **+ *Knee Stabilization***
* **RCT of 159 pts w/ knee OA**
* ****pts had knee instability verified w/ self-reported buckling OR giving way OR biomech. assessed instability of frontal plane laxity OR poor proprio
* Training focused on perception of knee position and motion to improve proprioceptive accuracy, and on maint. of static or dynamic control of the knee to limit consequences of high laxity
* EX. lunging w/ resistance and keeping neutral knee (no valgus/varus)
* 12wks, 2x/wk, 60mins, **Progressive training**
* **RESULTS:**
* ****IMPROVEMENT REGARDLESS OF GROUP ASSIGN. BUT.....
* Pts w/ **WEAKER Muscles** responded better to the **Control Intervention (Strength Training only)**
* Pts w/ **STRONGER Muscles** responded better to the **Knee Stabilization Intervention (bc had strength/muscle to perform better)**
* NOTE: **Adding knee stab. into treatment program may only be beneficial to indiv's who DO NOT have substantial LE mm weakness**
80
Passive Devices to control biomechanics in OA
examples?
1. variable stiffness shoe
2. **contralateral** cane
3. bilateral hiking post
4. unloader bracing
5. bracing w/ **extension assistance**
81
Passive devices
## Footnote
**Variable stiffness shoe**
* Reduces **ADD. moment** during tasks
* protects medial compartment in knee
82
Contralateral Cane especially good for....
Hip OA
\*good evidence to support\*
83
Bilateral hiking poles and OA???
Limtd evidence
84
Unloader brace and OA
**Evidence to support use**
Moves knee back to **neutral pos.**
85
PTs should NOT rely on passive devices **alone**
* Pts need to be aware and work on **improving sagittal plane motion**
* **\*part. @ IC, LR, MSt**
* Often the passive device is NOT enough and MAY req. add. relearning strategies
* **Passive + Motor Retraining + Therapeutric Exercise!!!**
**NOTE:** despite knee brace w/ EXT assist---\> pt will still use **flexed and stiff gait pattern**
86
passive+motor training should match the pts what?
Deficits!!!
* Ex. if **active terminal knee** **deficits** are present
* pt has normal ROM, **but lands w/ flexed knee**
87
Passive + motor retraining should match pts what?
diff. example...
Deficits!!!
* If pt has **varus thrust** during WB--\> use **targeted training** to reinforce normal mvmts during WB activities
* **Training** and **position** should match WHEN deficits occur during gait
88
Always start _______ and \_\_\_\_\_\_\_\_
start simple and progress
89
How do you monitor tolerance of progression?
2 ways:
* 1. monitor signs of **jt irritation or injury**
* ****Swelling
* **Effusion test==**indicates **intra-art. prob**
* tenderness to palpation
* 2. monitor **Pt reported outcomes**
* ****Pain+soreness
* Instability
* Stiffness
90
Effusion Testing
"Sweep Test"
Stroke UP **Medially**
Stroke DOWN **Laterally**
91
Quantifying Effusion
## Footnote
**Effusion Grade + Test Result**
* **Zero**
* ****NO wave produced w/ downstroke (**medial)**
* **Trace**
* ****SMALL wave on **medial side w/ DOWNstroke**
* **1+**
* ****LG bulge on **medial side** w/ **downstroke**
* **2+**
* ****Effusion spont. returns **after upstroke**
* **NO downstroke needed\*\*\*\***
* **3+**
* ****SO MUCH FLUID that it cannot be moved out of **medial aspect of knee**
92
When to **Slow Progression or Hold Tx**
## Footnote
**w/ Effusion grades**
* pts should NOT be progressed in ex. program when **effusion is 2+ or more**
* If **2+ persists despite effusion tx's ----\> contact MD**
* **Tx ex's**
* ****compress wrap, effusion massage, limb elevation, reduced WB/activity
* ANY **drastic change of 2 grades** OR **appearance of effusion when it was ABSENT**
* ****DEC act. to lvl prior to **effusion change**
* **GRADUALLY reintroduce act.**
93
**Soreness Rules** of Exercise Progression
## Footnote
**Joint Pain**
see pics
94
TKA Process
see pics
95
THA Process and Approaches
* Medial
* **Anterior**
* Anterolateral
* Direct Lateral
* **Posterior**
96
THA Precautions
## Footnote
**Posterior Approach**
* Do NOT **bend forward past 90deg**
* Do NOT **cross your legs**
* Do NOT **turn toes inward and Do NOT twist**
* Do NOT **turn knees inward or together**
97
Concerns EARLY after SX
## Footnote
**TKA and THA**
infection
DVT and PE
Wound dehiscence (tearing apart)
98
Concerns EARLY after SX
## Footnote
**THA**
Hip precautions!!!
Dislocation
Nerve issues (**part. sciatic or femoral)**
99
Concerns EARLY after SX
## Footnote
**TKA**
Nerve issues (**part. peroneal bc wraps around Fibular Head)**
100
Resolution of **pain** and **cartilage defects** does NOT **resolve all pt's impairments**
## Footnote
**T/F???**
TRUE!!!
* Pain resolves quickly after TKA
* **often not barrier after 6wks**
* OA==Chronic disease
* **dx'd decades before TKA**
* Mvmt patterns and NMSK control have "NEW" normal
* **pts cont to rely on "good" leg**
* **many pts AFTER TKA walk w/ _reduced knee flex==\>_** **Stiff-knee gait pattern**
101
Resolution of pain and cartilage defects does NOT resolve all pt's impairments
* TKA does NOT change pt **behavior or phys activity**
* **Even AFTER rehab,** strength does NOT exceed pre-op values\*\*\*\*\*\*
* **Functional tests:** important to measure **pt recovery BUT** do NOT provide info on **biomechanics**
* ****TUG
* 6MW
102
Pre-hab and Education
3 Outcomes:
* **Expectation setting**
* ****Respect timeline, pain, hospital procedures
* **Instruction on future HEP**
* ****Practice exercises\*\*\*
* **Environment set-up/Safety**
* ****raised toilet seat/shower chair
* assist @ home
* HIP PRECAUTIONS\*\*\*
NOTE: **Better you go IN===Better you come OUT (esp first week or 2)**
103
Prehab consists of:
Exercises for ROM, strength, endurance
104
Stage 1:
**Immediate Post-OP**
**Days 0-3**
* ******Safety, ADs, Gait**
* ****Hip Precautions
* **Education**
* ****HEP
* Infection
* **Determine discharge Location**
* ****Home vs. Rehab
105
Stage 1:
## Footnote
**Early Acute**
**Day 0--Week 2**
* Attenuate **swelling** and **prevent strength loss**
* **GENTLE ROM**
106
Attenuating **Swelling**
## Footnote
**Methods**
**Manual Lymph Drainage Massage**
10 min daily @ end of the day
## Footnote
**Pts measured swelling pre/post**
107
Swelling
## Footnote
**HEP**
**\*First 2 weeks**
```
# * Toe curling/Ankle DF **1 min ea. hour**
* Choose 1 of 4 additional ex's **5x/day**
```
**\*\*\*1 min of Ankle Pumps INCs Venous Return 22% for 30mins**
108
Physical Impairments during Early Stages post-op can include:
* **ROM**
* ****do NOT "overdo it"
* ID pts @ risk for **arthrofibrosis**
* **Strength (from day 1!!!!)**
* ****NMES
* lg pads
* MAX tolerable intensity
* **Active mm activation ON TOP OF NMES stimulated mm contraction**
* provide feedback
* **Maximize STRENGTH AND ACTIVATION!!!**
109
Addressing Activation Deficits:
* Strengh highly correlated w/ **Function**
* Even 1yr post TKA **pts strength SAME as pre-op values**
* **Quad focus**
* ****also hips, lower leg mm's
110
Addressing Activation Deficits:
## Footnote
**Multiple factors contribute to mm weakness:**
* Activation deficits
* Disuse atrophy
* Morphological changes
* Changes in **afferents/proprioception**
**\*\*NOTE:** contribution of hip ABD strength to phys function in pts w/ TKA
111
Stage 1 POST-OP
## Footnote
**Goals/Documentation**
* **Realistic pt-specific goals**
* Doc. pt activity @ **weekly sessions**
* ****obj. measures
* **steps/day, activity counts, mins of ex, HR based on *activity zones***
* **INC** activity target on **weekly basis**
* **% based INCs**
112
Stage 1 & 2 Combined
## Footnote
**Progressive Strengthening ==ESSENTIAL**
**HEP and Clinic**
**KEY WORD: ESSENTIAL !!!!!**
Focus on **Quality** and **Control** of mvmts
113
Stage 1 and Beyond
**Movement Retraining**
ex. Tapered mirror/visual feedback during gait
\***listening for symmetrical footstrikes**
114
Movement retraining for **gait** may NOT carry over to other activities
meaning....
End phases of pt rehab **should focus on pt-specific goals/whatever it is they want to get back to!!!!**
115
Running Progression
## Footnote
**Keep in mind you are progressing pt in TINY INCREMENTS**
see pics
116
Recommendations for **Athletic Activity after TJA???**
## Footnote
**Discouraged vs. Occasional vs. Unlimited**
see pics
117
Word of Caution on Recommended Activities
## Footnote
**Unlimited**
* Swimming
* Walking over EVEN ground
* Golf
* Cycling over EVEN terrain
* Walking stairs
118
Word of Caution on Recommended Activities
## Footnote
**NOT Recommended or NO Consensus**
**Based on OPINION**
* Climbing
* Skiing groomed trails
* Off road cycling
* Singles tennis
* Jogging
* Skiing diff. trails
* Sprinting
119
CPG for Pts After TKA
## Footnote
**Intervention Outline:**
* Continuous Passive Mvmt Device (CPM) for **mobilization**
* NMES
* Phys Activity
* Cryotherapy
* Resist. and Int. of Strengthening Ex.
* Knee Flex during rest for **swelling**
* Motor Function Training
* balance, walking, mvmt, symmetry
* Post-op Knee ROM ex's
120
**CPM Device for Mobilization:**
**Recommendation:**
PTs **should NOT USE** CPMs for pts who have undergone primary, uncomp TKA
**Evidence Quality:** HIGH
**Recommendation Strength:** MODERATE
\*There is INCd risk, harm, or cost
\*Positive, sig. results were contradicted by **high quality studies**
121
Cryotherapy
**Recommendation:**
PTs **SHOULD TEACH and ENCOURAGE** its use for **early post-op pain mgmt**
**Evidence Quality:** HIGH
**Recommendation Strength:** MODERATE
\*\*Insuff. evidence to support a specific app. method, aplication time frame, or days post-sx to continue cryo.
122
Knee Flexion During **Rest** for **Swelling**
**Recommendation:**
PTs **MAY teach** pts to pos. the operated knee in SOME DEGREE of FLEX while resting **during first week**
**\*\*\*Long term effect on ROM???**
**Evidence Quality:** HIGH
**Recommendation Strength:** WEAK
**Potential Unmeasured Risk:** Limtd Knee EXT
\*\*\*This can reduce **immediate post-op blood loss and swelling,** as well as improve **short term flexion ROM**
123
Physical Activity CPG
**Recommendation:**
PTs **SHOULD DEVELOP and Teach** appropriate progression of physical act, based on **safety, functional tolerance, and physiological response**
**Evidence Quailty:** INSUFF.
**Recommendation Strength:** BEST PRACTICE
\*\*This includes WB, balance, flex. activities which are shown to improve variety of outcomes; **42% of pts did NOT meet recommended lvls 1 yr after TKA \*\*\***
124
Motor Function Training
Balance, Walking, Mvmt Symmetry
**Recommendation:**
PTs **SHOULD INCLUDE** motor function training (balance, walking, mvmt symmetry w/ **visual feedback)**
**Evidence Quality:** HIGH
**Recommendation Strength:** MODERATE
**\*\***Improves balance, walking function, activities, participation
125
Post-Op Knee ROM Exercise
**Recommendation:**
PTs **SHOULD ENCOURAGE** and teach pts to implement **passive, active assist, and active ROM ex's** for the involved knee following TKA
**Evidence Quality:** INSUFF. (Current Standard)
**Recommendation Strength:** BEST PRACTICE
\*\*INCd range and function
\*\*DECd complications
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NMES
**Recommendation:**
PTs **SHOULD USE** NMES to improve **quad strength, gait training, performance-based outcomes,** and pt reported outcomes
**Evidence Quality:** HIGH
**Recommendation Strength:** MODERATE
\*\*Earlier NMES and more Frequent (mult x/day) app w/ **longer cumulative time @ max pt tolerance** improved outcomes
\*\*Apply for min. of 3wks
127
Resistance and Intensity of Strengthening Exercise
**Recommendation:**
PTs **SHOULD design, implement, teach and progress** the pt in **high-intensity strength training** and ex. programs **w/in first week after Sx**
**Evidence Quality:** HIGH
**Recommendation Strength:** MODERATE
\*\*Improves **function, strength, balance, ROM**
**\*\***HIGH and LOW intensity--\> equally safe
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