patients performed high-intensity and progressive exercises performed on land or in the water. Water-based therapy may be a good option for patients unable to tolerate land-based therapy, as similar outcomes between water-based and land-based therapy were found; however, water-based therapy was not found to be superior to land-based therapy. When thinking about a patient’s return to function, it may be more beneficial for a patient to exercise on land because that is where he will be performing functional-based activities. But water-based therapy is a good way to promote an increase in range of motion, strength, balance, and endurance for patients unable to tolerate land-based weight-bearing activities when compared to the alternative of avoiding weight-bearing activities all together. Following a total knee replacement, balance may be affected by a loss of strength, proprioception, range of motion, pain, and use of an assistive device. Balance is generally a key component noted by physical therapists in the rehabilitation protocols of patients following a total knee replacement. Balance deficits following a TKA can increase a patient’s risk of falling and may cause further injury and disability. A patient’s goals in the outpatient physical therapy setting following a TKA should include improving balance to decrease a patient’s risk of falls and improve functional independence (Pozzi et al., 2013). A study by Liao and colleagues (2013) evaluated the effectiveness of additional balance training on mobility and functional outcomes in patients with knee osteoarthritis following a total knee replacement. This study was a prospective intervention study and a randomized controlled trial where following a TKA, patients were randomly assigned to the experimental group or the control group. The control group received conventional function training for eight weeks. The experimental group received the same care as the control group but also received additional balance exercises in each session. Testing evaluated pretraining and post-training and included distance of functional forward reach, duration of single-leg stance, timed Sit-to-stand Test, timed Up-and-Down Stair Test, timed 10-minute walk, timed Up-and-Go Test, and the Western Ontario and McMaster Universities Osteoarthritis Index Score. Following eight weeks of intervention with additional balance training, the experimental group demonstrated significant changes in the 10-minute walk test and in the timed Up-and-Go. There were also significant changes in all other measures and in the WOMAC score for the experimental group. The conclusion of this study was that adding balance training to a postoperative total knee replacement rehabilitation program demonstrated a significant beneficial effect on the functional recovery and mobility outcomes (Liao et al.). Single-leg stance balance can improve with function-based and balance-based training according to previous studies (Liao et al., 2013). Single-leg stance performance and timed Up-and-Go tests are good prognostic factors for falls among older people. Duration of a single-leg stance of less than five seconds represents a defect in balance and is associated with a risk of injurious fall (Liao et al.). A single-leg balance score of less than 10 seconds in an older patient indicates a worse prognosis than for those patients who can maintain balance for more than 30 seconds (Liao et al.). Balance training for patients following a total knee replacement should help to reduce risk of future falls. It is important to perform balance testing early in the rehabilitation process, include balance interventions in the protocol, and perform testing throughout care to help Conclusion Knee OA affects many people and may or may not result in surgical intervention to restore function and decrease pain. The goals for physical therapy intervention are mostly the same preoperative and postoperative: to decrease pain and improve function. These goals can be achieved through a variety of interventions; however, there has not yet been one standard
determine possible risk of future falls to increase patient safety and function. Interventions that may be the focus of inpatient acute physical therapy, inpatient rehabilitation programs, and home health physical therapy differ from those of outpatient physical therapy settings. These settings focus more on restoring initial functional ability that includes self-care and mobility around one’s home rather than focusing on restoring all associated impairments. Initial interventions may include the following: ● Transfer training, including transfers on and off the toilet or chair, in and out of the car. ● Showering/bathing.
● Use of assistive device in the home. ● Managing stairs in the home safely. ● Dressing. ● Gait training. ● Medications for pain control. ● Cold therapy to reduce swelling. ● Early range of motion. ● Early strengthening. ● Controlling edema (Westby et al., 2014).
Interventions typically incorporated and continued once a patient progresses to the outpatient setting include the following: ● Passive/active range of motion. ● Strengthening. ● Stretching. ● Postural training. ● Home exercise program. ● Static/dynamic balance training. ● Neuromuscular re-education. ● Progression of gait training. ● Weaning off of an assistive device when able. ● Improving weight-bearing tolerance. ● Training on various surfaces. ● Reducing pain and swelling. ● Manual therapy techniques. ● Massage for scar mobility. ● Joint mobilization. ● Continued patient education (Westby et al., 2014). The patient may then be progressed to a normal level of activity and recreational activities within the prescribed parameters. A patient will typically be advised not to return to high-impact activities or activities that place too much stress on the knee joint, including running and jumping. It is also advised that a patient not perform repetitive kneeling on the affected knee to decrease wear on the prosthesis. A patient may require job modification suggestions and ergonomic assessments in the workplace to perform his job with the least amount of impact on the knee. The 2013 study by Pozzi and colleagues also looked at home- based therapy programs and outpatient physical therapy to see if there was a different in those patients who did not attend outpatient physical therapy. The trials looked at in the study suggested that outpatient physical therapy was not necessary following a TKA. But these trials lacked a methodological control, and subjects in all groups appeared under-rehabilitated (Pozzi et al.). These studies also did not provide evidence that home-based therapy or lack of outpatient therapy was superior to attending outpatient physical therapy (Pozzi et al.). Based upon these results, the researchers could not recommend that postoperative rehabilitation programs following a total knee arthroplasty exclude outpatient physical therapy or a supervised exercise program. protocol developed in the treatment of knee OA or in the management of a patient following a total knee arthroplasty. It is important to recognize that patients with knee OA and following a total knee arthroplasty are at a greater risk of falls. To reduce future fall risk it is important for them to undergo physical therapy interventions to restore strength and balance. Patients
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