rehab for total joints: from shoulder to hip to knee · tha wagenmakers et al. physical therapy...
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Rehab for Total Joints: From Shoulder to Hip to
Knee
Jaime Holt, PT, MPT, SCS, CSCS
Holt Physical Therapy & Performance Training
Twitter: @HOLTPT1
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information contained in this presentation.
Biography
APTA Sports Certified Specialist
NSCA Certified Strength and Conditioning Specialist
Owner and Sports Orthopaedic PT at Holt Physical Therapy & Performance Training
PT Consultant NHL Carolina Hurricanes (2007 –2014)
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Biography
East Carolina University
BS Exercise Physiology 1995
MS Adapted Physical Education 1997
MPT Physical Therapy 1999
Mentors
Pete Friesen
Doug Geiger
Gary Gray
Walt Jenkins
Bill Moore
Kevin Wilk
Co-workers
Patients!!
OutlineTKR
Current Research
Knee Anatomy
Radiographs
TKR/UKR/Mobile
Bearing
Exercises
THR
Current Research
Hip Anatomy
Radiographs
Ant vs Post
Exercises
TSR
Current Research
Shoulder Anatomy
Radiographs
Total vs Reverse
Exercises
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When is it time?
Lasts 15-20 years??
What advances will we make in next 15 years?
Why be miserable in life when there is an option to improve your quality of life?
Personally: Has to effect your every day activities/sleep etc. and the surgery has to be 80% successful
Incidence of Total Knee Replacements
Total Knee: Age 50+ Male: 3.4% Female: 4.8%
OA: Age 50+ Male: 9.4% Female: 13.3%
4 million Americans with TKA and 500,000 with TKR
11 million Americans dx with OA
31.6% males and 31.3% females with TKA
Pain after TKA
Efficacy of Myofascial Trigger Point Dry Needling in the Prevention of Pain after TKA: A Randomized, Double-Blinded, Placebo-Controlled Trial. Mayoral, Salvat, Martin, Martin, Santiago, Cotarelo, Rodriguez. Evidence Based Complementary and Alternative Medicine. 2013.
Half of the group TPDN pre-op after sedation
TPDN group reached the same degree of pain reduction in 1 month as the placebo group achieved in 6 months!
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Early NMES after TKA
Stevens-Lapsley et al. Physical Therapy February 2012
Study regarding early NMES to improve quadriceps muscle strength after TKA
Results: Significant benefit in NMES group one month post op but no difference at 1 year post op
Biofeedback after TKA
McClelland et al. JOSPT February 2012
Research study on functional and biomechanical outcomes after using biofeedback after TKA
Non-control group showed statistically significant improvement in strength, ROM, function and better symmetry in movement patterns.
Mobile Bearing vs. Fixed Bearings TKR
Bone and Joint Journal April 2013
Breeman, Campbell, Dakin, Fiddian et al
After 5 years TKR functional outcomes, re-operation rates and healthcare costs appear to be the same
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Health related Quality of Life after TKR or THA
Archives of Orthopaedic and Trauma Surgery Nov 2012
Improvements observed in the HRQOL at short term after surgery are at least maintained over 7 year follow up
Why choose UKA vs. TKA?
Orthopaedic Physical Therapy Secrets. 2nd Ed. Placzek and Boyce.
10 year survivorship of UKA in patients over the age of 60 is 96%!
CRITICAL to pick the right patient for this
Knee Arthritis
Most common cause of chronic knee pain and disability
Osteoarthritis (most common), rheumatoid arthritis, post-traumatic arthritis
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Pathological Changes in OA
Thinning and damage to articular cartilage
Subchondral bone sclerosis
Marginal bone and cartilage growth as osteophytes
Periarticular muscle wasting
Clinical Signs of an Acutely Infected Total Joint
Prosthesis
Wound dehiscence or drainage
Pain
Redness
Heat
Swelling
Loosening of prostheses is a sign later on
Total Knee: Anatomy
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Total Knee: Anatomy
Knee OA X Rays
Total Knee Radiographs
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Total Knee
Standard Total Knee
More long term outcome studies
Most common technique for surgeons
Very stable/strong
Standard expected results
Mobile Bearing Knee
Mobile-bearing prostheses permit a limited amount of rotation in the joint that fixed-bearing implants do not. When the mobile-bearing designs were introduced, it was hoped -- but never proven -- that they would increase range of motion.
Need increased strength with mobile bearing
May be more suitable for athletic population
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Unicompartmental Replacement
Quicker recovery
Less pain after surgery
Less blood loss
Because the bone, cartilage and ligaments in the healthy parts of the knee are kept, most patients report that a unicompartmental knee replacement feels more “natural”
TKR Initial Exercises
Patellar mobs
Quad sets with NMES
Heel slides
TKEs
Calf Raises
Weight Shifts
Straight Leg Raises
IT Band CFM
Ankle Pumps
HS stretches
Gastroc/Soleus stretches
TKR Videos
• Total Knee
• TKR Dynamic
• TKR Mini-band
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TKR: Advanced ExercisesHip Mini Band Exercises
LE isometric exercises
Step Downs
Star Reaches
Star Lunges
Sliders
Core Exercises
AIS Rope Stretches
Total Hip Replacement
Incidence of Total Hip Replacements
Total Hip Replacements: 332,000 performed per year
Increased 25% over past decade
Projected to increase 174% by 2030
Average surgical cost in the US is $17,000+
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Level of Activity 1 Year after THA
Wagenmakers et al. Physical Therapy 2011
Study on physical activity behavior of patients one year after THA
Patients that were more physically active had the following characteristics:
Younger in age, Male, Lower BMI
Functional Recovery during First Post Op Year THA
Journal of Biomechanics February 2011
one incision and two incision approaches
Daily step counts the same after 1 year
was decreased hip abduction strength at 1 year on two incision approach
Hip Strength Recovery w Direct Anterior and Posterior Approaches
Bone and Joint Journal , 2013
Rathod, Fukunga, Deshmukh, Ranawat and Rodriguez
Both DAA and PA offer similar recovery in muscle strength up to 6 months with expections of ER weakness in PA and hip flexion weakness in DAA at 6 weeks
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Reduced Post Op Pain in THA with minimal invasive anterior
approach
International Orthopedics, March 2012
Decreased overall post operative pain, decreased pain meds, decreased hospital stay time
Increased PT pain but could be due to being too aggressive due to approach
Total Hip Replacement: Anatomy
Total Hip Replacement: Anatomy
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Total Hip Replacement: Anatomy
Total Hip Replacement: Anatomy
THR: Radiographs
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THR: Radiographs
Total Hip Radiographs
Not What You Want!
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THR: Anterior vs Posterior Approach
Posterior Approach
Benefits
Proven track record of success
Low complication rate
Minimally invasive surgical approach available
No violation of abductor muscles
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Posterior Approach
Potential Risks
Early dislocation rate higher than anterior approach
Must follow hip precautions
Overall risk of hip dislocation is 1-2%
Total Hip Precautions
Usually til 6 weeks post op with posterior approach but......
No hip flexion greater than 90 degrees
No hip adduction
No hip internal rotation
Anterior Approach
Benefits
4 inch incision in front of leg between glute med and TFL
Can reach the joint by separating the muscles not cutting them
Swifter recovery?
Shorter hospital stays
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Anterior Approach
Potential Risks
Substantial risk of a numb, burning or tingling sensation in the front of the thigh due to proximity of lateral femoral cutaneous nerve
Not candidates: previous metal implants, muscular, wide pelvis or very obese
THR: Initial ExercisesPost Op Day 1 to Week 2
Heel slides
Quad sets
Glute sets
SLR ?
Ankle pumps
Supine abduction
Weight shifts
Mini squats
Gait training
WB on involved: hip flex, abduction and extension
Encourage heel to toe gait
THR: Initial ExercisesPost Op Day 1 to Week 2
Heel slides
Quad sets
Glute sets
SLR ?
Ankle pumps
Supine abduction
Weight shifts
Mini squats
Gait training
WB on involved: hip flex, abduction and extension
Encourage heel to toe gait
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THR: Exercise ProgressionWeeks 3-6
Soft tissue prn
Anterior/Medial step ups/downs
Mini squats with T band
Balance Exercises
Sliders
LE Reaches
Gait train: progress from SPC to independent
T Band supine abd
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THR: Advanced ExercisesWeeks 7-12
Initiate sidelying abduction
T Band hip flexion, extension and abduction
LE isometrics
ROM goals: 110 flexion, 30 abduction, 0 extension
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Total Shoulder Replacement
Incidence of Total Shoulder Replacements
Total Shoulder
Approx 27,000 shoulder arthroplasties and 20,000 hemiarthroplasties per year
2/3 in adults age 65 or older
OA primary dx in 43% of hemiarthroplasties and 77% of arthroplasties
Humeral fracture top primary dx leading to hemiarthroplasty
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Revision using Reverse Design Prosthesis
Bone and Joint Journal, May 2013
Abdel, Hattrup, Sperling, et al
Decreased pain, increased, fwd flexion
No diff in ER/IR
94% stable at 3 year follow up
40% excellent, 30% satisfactory, 10% unsatisfactory
Hemiarthroplasty vs TSR for Rotator Cuff Intafct OA
Journal of Shoulder and Elbow Surgery, 2012
Sandow, David, Bentall
6 mos and 1 yr follow up
TSR had less pain, even more so at 2 years
10 years: no diff in function/daily activities
0% HA had no pain and 42% TSR were pain free
Total Shoulder Anatomy
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Shoulder Anatomy
TSR: Radiographs
TSR: Radiographs
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Goal of Total Shoulder Replacement
DECREASE PAIN!!!
Total Shoulder
A conventional shoulder replacement device mimics the normal anatomy of the shoulder: a plastic "cup" is fitted into the shoulder socket (glenoid), and a metal "ball" is attached to the top of the upper arm bone (humerus).
Total Shoulder
A conventional replacement device also uses the rotator cuff muscles to function properly. In a patient with a large rotator cuff tear and cuff tear arthropathy, these muscles no longer function. The reverse total shoulder replacement relies on the deltoid muscle, instead of the rotator cuff, to power and position the arm.
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Reverse Total Shoulder
In a reverse total shoulder replacement, the socket and metal ball are switched. The metal ball is fixed to the socket and the plastic cup is fixed to the upper end of the humerus.
Reverse Total Shoulder
A reverse total shoulder replacement works better for people with cuff tear arthropathy because it relies on different muscles to move the arm. In a healthy shoulder, the rotator cuff muscles help position and power the arm during range of motion.
TSR: Protection PhaseGoals
Protect healing repair
Decrease pain and swelling
Preserve strength of the elbow, wrist and hand
Initiate AAROM
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TSR: Protection Phase(1-2 Weeks)
FF to 90 deg
Abd to 75 deg
ER to 30 deg/45abd
IR to 30 deg/45abd
Cont to progress PROM
Initiate joint mobs
Cont initial HEP
Modalities to decrease pain and swelling
Initiate AAROM flex/abdw pulleys and UBE
Isometrics all planes except IR (6 weeks)
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TSR: Protection PhasePrecautions
No lifting heavier than a coffee cup
While lying in supine position, place pillow behind elbow to limit shoulder extension
Keep incision clean and dry
No quick, sudden movements
TSR: Controlled Strengthening Phase Goals
Protect healing of surgery
Begin to strengthen periscapular muscles
Continue to gradually increase PROM
Progress AAROM
TSR: Controlled Strengthening Phase (3-4 Weeks)
FF to 120 deg
Abd to 90 deg
ER to 50 deg/75abd
IR to 45 deg/75abd
DC sling at 4 weeks
Cont PROM FF and IR
Keep ABD below 90 degand ER less than 50 deg
Table slides (flex, ER and abd)
Cont modalities
Initiate isometric scapular proprioceptive exercises
Initiate light biceps and triceps strengthening
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TSR: Controlled Strengthening Phase Phase
Continue with previous precautions
TSR: Strengthening PhaseGoals
Protect repair
Progress strengthening of scapular muscles; initiate strengthening of RTC muscles
Progress AAROM to AROM
Increase PROM
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TSR: Strengthening Phase 6 Weeks
FF to 140 deg
Abd to 120 deg
ER to 75 deg/45Abd
IR to 45 deg/90Abd
Increase UBE
Pulleys
Progress scapular proprioceptive exercises to PRE (T band, DB)
AROM exercises: SL ER, prone flexion, prone HABD, standing scaption
Initiate resistance for IR isometrics
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TSR: Strengthening Phase8 Weeks
Progress patient to full ROM in all planes, equal to unaffected side
Initiate T Band IR/ER
Progress SL ER to PRE
Continue to progress AROM exercises (prone HABD with ER, UE PNF)
TSR: Strengthening Phase Precautions
No lifting greater than 5 pounds with outstretched arm
No sudden lifting or pushing activities
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TSR: Advanced Strengthening Phase Goals
Progress strengthening
Continue to increase ER ROM
Initiate functional strengthening
Begin functional training (return to sport or work)
TSR: Advanced Strengthening Phase 10 Weeks+
Continue w RTC and scapular PRE’s
Initiate stabilization exercises (Body Blade, WB stabilization exercises, rhythmic stabilizations)
Progress single arm prone exercises
Gradually return the patient to pre-morbid activity level
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TSR Videos
• Shoulder Video #1
• Stick Work
• Shoulder Video #2
• Shoulder Strength #1
• Shoulder Strength #2
• Tennis
Return to Work/Sport
Per MD recommendation
Patient must have full ROM and 5/5 strength in all planes to be considered for return to sports and jobs requiring manual labor/lifting
Conclusion
Questions?
Twitter: @HOLTPT1
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References• Abdel MP, Hattrup SJ et al. Revision of an unstable hemiarthroplasty or anatomical total shoulder
replacement using a reverse design prosthesis. Bone Joint J May 2013 vol. 95-B no. 5 668-672
• Stevens-LapsleyJE, Balter JR, Wolfe P, Eckhoff DG and WM Kohrt. Early Neuromuscular Electrical Stimulation to Improve Quadriceps Muscle Strength After Total Knee Arthroplasty: A Randomized Controlled Trial. Physical Therapy, February 2012 Vol. 92 No. 2 210-235
• Hadley S , Day M , Schwarzkopf R , Smith A , Slover J , Zuckerman J . Is Simultaneous Bilateral Total Knee Arthroplasty (BTKA) as Safe as Staged BTKA?. American Journal of Orthopedics. 01 Jul 2017, 46(4):E224-E229
• Wagenmakers R, Stevens M, Groothoff JW, ZijlstraW, et al. Physical Activity Behavior of Patients 1 Year After Primary Total Hip Arthroplasty: A Prospective Multicenter Cohort Study. Physical Therapy, March 2011 Vol. 91 No. 3 373-380.
• Mcclelland J, Zeni J, Haley R and L Snyder-Mackler. Functional and Biomechanical Outcomes After Using Biofeedback for Retraining Symmetrical Movement Patterns After Total Knee Arthroplasty: A Case Report. JOSPT, February 2012 Vol. 42 No. 2 135-144.
• Sandow M, David H and Bentall S. Hemiarthroplasty vs total shoulder replacement for rotator cuff intact osteoarthritis: how do they fare after a decade? J Shoulder and Elbow Surgery; Vol 22: Issue 7; July 2013: 877-885.
References
Ethgen O, Bruyere O, Richy F, Dardennes C and J Reginster. Health-related quality of life in total hip and total knee arthroplasty: A Qualitative and Systematic Review of the Literature. JBJS. Vol 86; Issue 5; May 2004. 963-974.
• I. A. Malek, G. Royce, S. U. Bhatti, J. P. Whittaker, S. P. Phillips, I. R. B. Wilson, J. R. Wootton, I. Starks. A comparison between the direct anterior and posterior approaches for total hip arthroplasty the role of an ‘Enhanced Recovery’ pathway. The Bone & Joint Journal. 27 May 2016.
• BreemanS, Campbell M, Dakin H, Fiddian N, et al. Five-year results of a randomised controlled trial comparing mobile and fixed bearings in total knee replacement
• Mayoral O, Salvat I, Martin MT, et al. Efficacy of Myofascial Trigger Point Dry Needling in the Prevention of Pain after Total Knee Arthroplasty: A Randomized, Double-Blinded, Placebo-Controlled Trial. Evidence-Based Complementary and Alternative Medicine. Vol. 2013, Article ID 694941, 8 pages, 2013. doi: 10.1155/2013/694941
• Goebel S, Steinert AF, Schillinger J et al. Reduced postoperative pain in total hip arthroplasty after minimal-invasive anterior approach. International Orthopaedics. March 2012, Vol. 36, Issue 3, pp 491-498.
References
• Rathod P, Fukunaga T, DeshmukhA, Ranawat A and J Rodriguez. Hip Strength Recovery with Direct Anterior and Posterior Approach Total Hip Arthroplasty: Are There Any Differences?. Bone and Joint Journal 2013. Vol. 95-B No. Supp 15, page 312.
• Orthopaedic Physical Therapy Secrets. 2nd edition. Jeffrey D. Placzek and David A. Boyce. Elsevier Mosby. 2006.
• Tennent, David J. MD; Hylden, Christina M. MD; Johnson, Anthony E. MD; Burns, Travis C. MD; Wilken, Jason M. PhD; Owens, Johnny G. mPT. Blood Flow Restriction Training After Knee Arthroscopy: A Randomized Controlled Pilot Study. Clinical Journal of Sport Medicine: May 2017 - Volume 27 - Issue 3 - p 245–252
• G. Klingenstein, S. Schoifet, J. Reid, R. Jain, M. Porat . RAPID DISCHARGE AFTER TOTAL KNEE ARTHROPLASTY IS SAFE IN THE MEDICARE POPULATION. The Bone & Joint Journal. 20 February 2017.