2010). This is often achieved with the use of bracing to provide prolonged low-load stretching throughout the day. Lower extremity weakness, especially of the quadriceps muscle, is a universal finding after TKA. Up to 27% of quadriceps weakness that results in poor functional performance is caused by postoperative swelling, with increased knee circumference strongly correlating with decreased knee extension strength and the reduced ability to walk quickly (Holm et al., 2010). Quadriceps strength can take more than 2 years to return to preoperative levels after TKA, and it is a critical component of recovery (LaStayo et al., 2009; Saleh et al., 2010). Quadriceps strength gains may be achieved through a combination of progressive resistive exercises and neuromuscular electrical stimulation (NMES) to increase muscle activation and quadriceps volitional force output (Saleh et al., 2010; Stevens-Lapsley 2012). High-intensity strength training programs and the use of NMES as early as 2 days postoperatively may be effective in addressing this pervasive impairment after TKA (Bade & Stevens-Lapsley, 2011). Similarly, the hamstring muscles show weakness and an impaired ability to co-contract with the quadriceps after surgery, as seen in electromyographic studies (Stevens-Lapsley, Balter, Kohrt, & Eckhoff, 2012). However, therapists may wish to focus on quadriceps muscle bulk as a measurable parameter because quadriceps muscle volume is more strongly correlated to quadriceps strength at 1 year post- TKA than the amount of quadriceps activation as measured electromyographically (Meier et al., 2009). When focusing on enhancing lower extremity muscle volume through resistance exercises, measurable improvements in quadriceps bulk, knee extension strength, and functional mobility can be seen in as little as 12 weeks, even if patients are 1 to 4 years post-TKA surgery (LaStayo et al., 2009). The positive effects of muscle growth and strength are enhanced by incorporating resistance exercises that include eccentric strengthening exercises (LaStayo et al., 2009). Patients with bilateral TKA may benefit from alternating between the operated legs while performing strengthening exercises. One study showed that patients who alternated between the left and right leg with each repetition instead of exercising one leg at a time Return to sports The pain associated with advanced knee arthritis often prohibits participation in most sport-related activities. One of the goals in undergoing TKA for an increasing number of patients is to return to a desired sporting activity. This may in part account for the increased number of TKAs that are performed each year, as younger patients are seeking joint replacement as a means to return to meaningful activities, including sports and leisure activities (Julin et al., 2010). Traditionally, patients were advised to refrain from participating in high-load or high-impact activities after TKA, in an effort to reduce stresses and prolong the life of the prosthetic implant. In most cases, surgeons advise patients to avoid any work or sport activities that will involve running or jumping, or repetitive or excessive loading, such as basketball, soccer, high-impact aerobics, singles tennis, squash, racquetball, and alpine skiing (Heislein & Eisemon, 2016). Patients must be cautioned against overloading implant components that may cause early wear and aseptic loosening and are advised to control their weight. Participation in low-impact or lateral-movement sports such as golf, doubles tennis, cycling, swimming, tai chi, and bowling appears to be safe if the patient was proficient in those sports prior to surgery (Billante & Diduch, 2009).
resulted in an earlier return to functional independence and decreased pain levels, although the exact mechanism is unclear (Liu et al., 2009). Balance and movement retraining is another important part of recovery, as patients post-TKA demonstrate deficits in both coordination and balance, possibly due to the loss of joint mechanoreceptors and the need for accurate perioperative soft- tissue balancing because joint deformities are corrected during surgery. Recovery of proprioception is slow and may require therapeutic intervention for up to 6 weeks to develop static and dynamic postural control and compensatory responses at the hip and ankle (Gauchard, Vançon, Meyer, Mainard, & Perrin, 2010). Patients with TKAs demonstrate decreased joint position sense, postural control, and amplitude of lower extremity muscle activity. They can benefit from functional exercises that incorporate sudden starts and stops, turning, twisting, standing, and walking on unstable surfaces, and negotiating obstacles to improve stiffness, gait speed, and static and dynamic balance (Piva et al., 2010). Most patients regain enough lower limb coordination to return to independent driving after 8 weeks (Williams et al., 2010). Even simple functional activities such as kneeling must be formally addressed post-TKA. Whereas some patients are fearful of kneeling, it is a necessary position to achieve in order to get up and down from the floor safely, and many patients consider the act of kneeling to be an important functional goal. In kinematic studies on patients who had experienced TKA, the average amount of knee flexion needed to kneel successfully varied from 107º to 128º; the studies suggested that for patients who were pain free and who desired to participate in kneeling activities, there was no harm and no incidences of prosthetic subluxation or injury (Hamai et al., 2008; Hanson et al., 2007). Factors such as flexion ROM, scar position, residual numbness, and pain can also affect the ability of a patient to safely get into and out of a kneeling position, but only patients who receive formal physical therapy instruction during the recovery period on how to kneel on the operated limb are able to do so at 1 year post-surgery (Jenkins, Barker, Pandit, Dodd, & Murray, 2008). In a study exploring the ability to return to golf after TKA, golfers reported that they were able to return to golf within 6 months post-TKA, but the vast majority (86%) still had to use a golf cart to get around the course (Jackson, Smith, Shah, Wisnewski, & Dahm, 2009). Williams et al. examined predictors for return to sports following joint arthroplasty surgery. For TKA they report the following factors were predictive of return to sport: younger age, male sex, lower BMI, and preoperative level of activity (Williams, Greidanus, Masri, Duncan, & Garbuz, 2012). The rate of returning to sport activities is high (93%) in younger patients after unicompartmental knee arthroplasties; however, patients modulated the intensity of the activity to a lower-impact sport based on the recommendations of their surgeon (Walker et al., 2015). Walking and other lower-load activities should be encouraged in the overall management of the patient, as participation will help maintain strength gains achieved in rehabilitation and provide overall health benefits from regular physical activity (Heislein & Eisemon, 2016). Sport-specific training may be required near the end of the rehabilitation process, especially if there are specific ROM, strength, or balance requirements to perform the task correctly. Gaining confidence in their ability to participate under the guidance of the physical therapist is likely to increase their overall participation.
OUTCOMES
Total knee arthroplasty is considered a very successful procedure to alleviate the pain and functional disability associated with knee arthritis. Outcomes after TKA can be measured in a variety of ways. Surgical outcomes include implant survival, wound issues, and local infection, as well as medical complications.
Impairment-level outcomes include factors such as pain, ROM, muscle performance, or strength. Functional ability and participation in social and physical activities can be measured in an objective or subjective manner. Therapists and patients collaboratively set clinical goals to facilitate recovery, and
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Book Code: PTNY3622B
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