complete this training or reinforce proper technique during physical therapy interventions. Data from the 22 rehabilitation facilities participating in the JOINTS study revealed an inverse relationships between length of stay and the intensity of physical and occupational therapy – the longer the length of stay; the less intense the rehabilitation services (DeJong et al., 2009). Unfortunately, few studies are available that solely detail the importance of occupational therapy in TKA recovery, and further research in this area is needed. Therapeutic exercise is focused on joint ROM and quadriceps activation/strengthening. Advancement of exercise beyond the isometrics given on POD#1 is initiated once the patient can actively contract the quadriceps, and this may include terminal knee extension from a slightly flexed position over a bolster or towel roll. This exercise can be progressed to full knee extension from a seated position with a focus on both concentric activation and eccentric control. If the patient is able to complete this exercise without difficulty, manual, cuff weight, or elastic band resistance can be added; however, for most patients, they do not attain this level of strengthening while in the acute care setting. ROM exercises initially may be passively performed and progressed to active-assisted exercises. For patients who presented to surgery with a knee flexion contracture, gaining extension ROM may take more effort. Knee extension can be facilitated by propping a towel roll or bolster under the lower leg. Some patients improve by utilizing a knee immobilizer at night for a prolonged low-load stretch. To gain flexion ROM, positioning the patient in a seated position will allow gravity to assist with the motion. The therapist can assist the knee into more flexion, or the patient can scoot forward in the chair with the foot planted on the ground to increase knee flexion. Many patients have reduced aerobic capacity, because the months leading up to surgery were limited in physical activity due to pain. Participation in basic functional mobility using an assistive device is often taxing to their cardiorespiratory systems. Progressive ambulation with increased distance is often adequate to attain a training effect. If the patient has underlying comorbidities in the cardiac or pulmonary systems, then specific training parameters should be set based on their preoperative testing and either heart rate or rating of perceived exertion (RPE) scale can be used to establish training parameters. Discharge planning There are multiple factors that need to be considered in determining the patient’s discharge disposition and where they will continue their recovery. Typical treatment goals for home Post-acute rehabilitation Following discharge from the acute care setting, rehabilitation may be provided in an inpatient facility, such as a rehabilitation hospital, a transitional care unit, or skilled nursing facility; in the home; or in an outpatient clinic. Regardless of the setting, the goal of rehabilitation is to advance the care initiated in the acute care setting, progress the exercise program according to each patient’s needs, and encourage patients to treat their recovery as a full-time job. Examination and interventions Examination is focused primarily on assessments of strength and ROM, however functional activities are monitored on a regular basis and refinement of gait and functional challenges identified by the patient are evaluated as well. Evidence to support specific physical therapy programs following TKA is lacking largely due to the variations in content and duration. A recent systematic review and meta-analysis demonstrated short- term improvements in function, but did not demonstrate any long-term effects on patient reported function, pain, ROM, and walking performance (Artz et al., 2015). The goals for this stage of rehabilitation are focused on knee ROM, quadriceps strength, and functional mobility. Once the surgical wound is healed, patients may participate in aquatic therapy, which can serve as an exercise motivator and help improve strength. In a study
discharge from the acute care setting include active-assisted ROM of 0º extension to 90º of flexion; independence with bed, chair, and car transfers; independent ambulation up to 150 feet using a wheeled walker; and independence with stairs, if necessary for the return to home, with an assistive device or the assistance of a caregiver (Cook, Warren, Ganley, Prefontaine, & Wylie, 2008). Many patients are able to go directly home 2 to 3 days after surgery once they have attained independence in basic functional mobility. Others will require discharge to an inpatient rehabilitation facility for further recovery before they are ready to go home. As part of the patient care team, the physical therapist begins discharge planning on the first day of care. Interdisciplinary planning among the patient’s healthcare team is focused on the unique needs of the patient. The overall health of the patient, his or her social supports in the home setting, and the physical environment of the home are all important considerations, in addition to their performance with functional mobility. Patients who live alone, have comorbidities that impact their progression with physical therapy, or have a challenging home environment to navigate will require discharge to an inpatient rehabilitation facility. Patients who are able to achieve independence in functional mobility, are medically stable, have social supports to assist with household management, and have minimal environmental obstacles in the home typically will go directly home from the acute care setting (Barsoum et al., 2010). The Risk Assessment and Prediction Tool (RAPT) was developed as a preoperative screening tool to help determine discharge disposition following total hip or total knee arthroplasty surgery (Oldmeadow, McBurney, & Robertson, 2003). This easy-to- complete tool calculates a score base on the patient’s age, gender, preoperative walking ability, use of assistive devices for ambulation, and social support in the home. The RAPT tool has been validated in a number of studies to aid in early discharge planning (Ariza, Badia, Cuixart, Fernández-Martínez, & Trujillano, 2012; Dauty, Schmitt, Menu, Rousseau, & Dubois, 2012; Hansen et al., 2015; Konopka, Hansen, Rubash, & Freiberg, 2015). Patients who score below 6 out of 12 points typically require an inpatient discharge setting for ongoing rehabilitation. Those who score greater than 9 out of 12 points are successful in discharge directly home. For patients who fall in the middle range, careful attention to individual circumstances and progression during the acute care stay will guide the discharge decisions (Oldmeadow et al., 2003). An online resource for this tool can be found at https://www.ahsa.com.au/web/patient_info/rapt_form/download by Valtonen and colleagues, patients who engaged in aquatic progressive resistance training for a 12-week period increased quadriceps and hamstring strength and were able to walk and ascend stairs faster than controls (Valtonen, Pöyhönen, Sipilä, & Heinonen, 2010). Therapists use a variety of methods when helping patients regain knee flexibility, ranging from active-assisted stretching to dynamic movement activities and from passive stretching to contract-relax techniques. One study compared the changes in knee flexion ROM over a 2-week period in patients with TKA after undergoing active stretching, passive stretching, and proprioceptive neuromuscular facilitation stretching, and found that Active Range of Motion (AROM) and Passive Range of Motion (PROM) measurements improved in all three groups to a similar degree, but with a slight advantage in the passive stretching group (Chow & Ng, 2010). One of the equipment mainstays in the outpatient clinic to promote knee flexion ROM and quadriceps strength and to provide a warm- up activity prior to other exercises is the lower body ergometer or exercise bicycle; however, cycling does not appear to produce any advantages in physical function after TKA (Liebs et al., 2010). When faced with a persistently stiff, arthrofibrotic knee, static progressive stretching can significantly improve active knee flexion by as much as 19º in 7 weeks (Bonutti, Marulanda, McGrath, Mont, & Zywiel,
Book Code: PTNY3622B
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