inpatient rehabilitation facility. The entire team of care providers, including the orthopedic surgeon, physician, nurse, physical and Acute care rehabilitation Clinical pathways have been developed as a standardized way to organize patient management after TKA. Clinical pathways are used to streamline the overall care of the patient, to identify and address any deviations from standardized care with the focus of improving the quality of care, and to reduce the overall cost of care (Berend, Lombardi, & Mallory, 2004). These pathways outline all aspects of care provided for the patient from all disciplines involved in the individual’s care. Many “fast track” recovery protocols call for rehabilitation to begin the day of surgery, and with new pain control regimes, patients can successfully begin mobilization and weight bearing within hours of surgery. If the patient is not ready to begin physical therapy on the day of surgery, barring any medical complications, it is expected that the patient will start on postoperative day one (POD#1). Restoring knee ROM after TKA will improve functional mobility and prevent the development of postoperative fibrosis, which may require MUA. Use of a continuous passive motion (CPM) device was considered standard care for patients during the acute care stay in previous decades to regain knee ROM. Research examining the effect of CPM on outcomes consistently fails to show a significant long-term benefit of CPM use after TKA in terms of ROM results, pain, length of stay, cost, and complications (Barbieri et al., 2009; Harvey, Brosseau, & Herbert, 2014; He et al., 2014; Herbold et al., 2014; Maniar, Baviskar, Singhi, & Rathi, 2012). Despite the lack of evidence to support the use of CPM, some physicians still follow old protocols, so clinicians still may see CPM recommendations following TKA. Protocols for the amount of use have not been established; however, longer duration of use prohibits functional mobility and active exercise, which are vital to effective recovery in the early days following TKA (Kim et al., 2009). In addition the American Physical Therapy Association has included the use of CPM following uncomplicated TKA as something therapists and patients should question on their “Choosing Wisely” initiative, given the lack of evidence to support its use in this particular patient population (American Physical Therapy Association [APTA], 2015). Examination and interventions Physical therapy interventions are developed following a comprehensive examination of the patient, and goals are tailored to the specific needs of the individual patient. Patients must be approached as individuals, because each patient had TKA surgery with particular goal in mind. Research describes a relationship between a patient’s goals and postoperative recovery, in that patients who elect to have TKA to alleviate pain are more likely to report high levels of pain during the subacute period of recovery, and patients whose goals are focused on regaining functional mobility or the ability to engage in a specific activity will experience greater ROM during the subacute phase of recovery (Creameans-Smith, Boarts, Greene, & Delhanty, 2009). In general, patients who choose TKA surgery with “approach” goals, in which they are working toward something functional, report less pain at 1 and 3 months post-surgery than patients who seek TKA for “avoidance” goals of reducing pain (Creameans-Smith et al., 2009). The initial physical therapy examination will include a thorough history taking with the patient, including any medical comorbidities, medication use, prior level of physical activity, and an assessment of their home environment and social supports available to assist them at discharge. Examination techniques are streamlined to gather critical information to begin functional training, because patients may have limited tolerance to participation on their first physical therapy visit. Assessments should include pain levels, baseline vital signs, and gross screening of the uninvolved extremities for functional
occupational therapists, rehabilitation staff, and family members, all assist in helping patients regain their mobility and function.
ROM and strength. Examination of the involved limb includes knee ROM, quadriceps activation and active motor control of the lower extremity, and gross screening of sensation. Further areas of examination are dictated by the patient presentation and their medical history. Physical therapy interventions on POD#1 are focused on functional training to assist the patient with transfers in and out of bed and on initiating an exercise program for knee ROM and lower extremity exercises such as quadriceps and gluteal sets, supine heel slides, active ankle pumps for calf flexibility and circulation, and deep breathing exercises and secretion clearing when indicated (Heislein & Eisemon, 2016). Pain control is a major consideration in the early phases of recovery, because pain will greatly affect the patient’s ability to participate in exercise and functional training. Coordination of medication administration with physical therapy interventions is important, because participation in functional training and exercise can escalate their pain. Advancements in the use of multimodal pain management strategies is the most effective way to manage postoperative pain. These strategies include the use of “preemptive” medications including acetaminophen or selective nonsteroidal anti-inflammatory drugs (NSAIDs), antineuropathic and antinausea agents; femoral nerve blocks or periarticular injections; and scheduled dosing with oral opioid analgesics (Baratta, Gandhi, & Viscusi, 2014). Titrating medications to maximize pain control and minimize side effects such as altered mental state, nausea, or vomiting is critical to allow full participation in their rehabilitation. In addition, other nonpharmacological pain modulating strategies such as femoral nerve blocks or intraoperative periarticular injections of anesthetic agents have been used. Femoral nerve blocks are often associated with reduced quadriceps function and have resulted in patient falls. Periarticular injections have demonstrated equally effective pain control and higher rates of achievement in functional milestones for discharge (Yu, Szulc, Walton, Bosco, & Iorio, 2016). While great strides have been made recently in pain management for this procedure, more research is needed to further refine strategies that can be tailored to the individual patient to maximize their recovery. Even with excellent pain control, patients will need to use an assistive device, such as a walker or crutches, to assist in transfers and gait training. Quadriceps function is typically impaired postoperatively, not only from preoperative weakness, but also due to activation failure or inhibition associated with knee effusion (Holm et al., 2010). For patients who have poor quadriceps control due to activation failure or from the presence of a femoral nerve block, temporary use of a knee immobilizer will assist the patient in gaining independence in transfers and ambulation. Immobilizers are also often used in patients who have simultaneous bilateral TKA, as neither knee is sufficiently strong to assist in sit-to-stand tasks. Most patients are allowed full weight bearing immediately after surgery, however the patient initially may be hesitant to put full weight on their involved lower extremity because of lack of adequate motor control. As the patient’s strength, motor control, and confidence improve, they can be advanced to a less restrictive assistive device, such as one crutch or a cane. Prior to discharge, gait training on stairs is required based on the patient’s home environment. Even if they do not have any stairs at home, it is important to train the patient on proper technique so that they are safe to negotiate stairs and curbs in their community. The patient may also require training with adaptive equipment, such as long handled sponges, reachers, and sock aids, to facilitate independence in bathing and dressing. Most often this training is completed by the occupational therapist, but there may be times when the physical therapist needs to
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