rehabilitation for the postsurgical orthopedic patient mitchell goldflies, md
TRANSCRIPT
Rehabilitation For The Postsurgical Orthopedic Patient
Mitchell Goldflies, MD
Musculoskeletal Conditions
• Etiology– Acute– Overuse– Degenerative
• Primary Lesions• Secondary Lesions
– Biomechanics– Ergomonics– Training Errors– Body Composition– Innervation-Referral Pattern
Musculoskeletal Conditions
• Evaluation Includes– Medical Condition– Mental Condition– Nutritional Status– Family History– Past Medical History– Litigation– Secondary Gain– Compliance– Belief System
Soft Tissue Healing Following Trauma and Surgery
• Surgery is Controlled Trauma Produced By a Trained Professional To Correct Uncontrolled Trauma
• Connective Tissue Responds in a Characteristic Way to Immobilization and Trauma
• Connective Tissue is 16% of Body Weight and 25% of Body Water Content
Soft Tissue Healing Following Trauma and Surgery
• Connective Tissue– Ligament– Tendon– Perisoteum– Joint Capsule– Aponeurosis– Nerve– Muscle Sheath– Blood Vessel Wall– Bed and Framework of the Internal Organs
Soft Tissue Healing Following Trauma and Surgery
• Connective Tissue Components– Cells– Extracellular Matrix– Fibroblast
• Synthesizes Inert Components – Collagen– Elastin– Reticulin– Ground Substance
Soft Tissue Healing Following Trauma and Surgery
• Connective Tissue Types– Dense Regular: Ligaments and Tendons– Dense Irregular: Joint Capsule, Perisoteum,
Aponeurosis– Loose Irregular: Fascia, Muscle, Nerve
Sheath
Soft Tissue Healing Following Trauma and Surgery
• Connective Tissue Biomechanics– Viscoelastic
• Elastic-Temporary Deformation• Viscous-Plastic-Permanent Deformation
– Shock Attenuation
• Immobilization– Fibrofatty Infiltration– Fibrous Adhesions– Dehydration
Soft Tissue Healing Following Trauma and Surgery
• Remobilization– Well Ordered Collagen Along The Lines of
Force– Reduction in Cross Links– Production of Ground Substance– Rehydration– Adhesions Rupture
Bone Healing Following Trauma And Surgery
• Stages of Healing: Overlap– Inflammatory Phase 10%– Repair 40%
• Removing Debris
– Remodeling 70%– Results
• Restoration of Original Tissue• Scar• Excessive Repair• Failure of Healing
Bone Healing Following Trauma And Surgery
• Injury Variables– Type of Injury– Intensity and Duration of Force– Tissues Involved– Patient Age– Nutritional Status– Genetic, Systemic and Local Disease– Smoking
Bone Healing Following Trauma And Surgery
• Management– Resuscitation of Patient– Clinical Assesment– Debridement if Open– Reduction
• Manipulation• Traction• Operative Reduction
Bone Healing Following Trauma And Surgery
• Management– Immobilization
• Prevent Displacement or Angulation• Prevention of Motion
– Rigid– Controlled Motion
• Relief of Pain
Bone Healing Following Trauma And Surgery
• Energy (High or Low)• How Force Applied (Direct or Indirect)• Level
– Articular– Metaphsyeal– Diaphsyeal
• Soft Tissue• Bone Deficits• Associated Conditions (Smoking, Diabetes,
PVD, Bone Disease, Steroids, NSAIDS)
Bone Healing Following Trauma And Surgery
• Procedure– Closed – Percutaneous– Limited Open– Open
• Fixation– Internal– External– Combined
Bone Healing Following Trauma And Surgery
• Fixation– Rigid– Flexible– Bioabsorable
• Graft Material– Synthetic– Allograft– Autograft– Xenograft
Bone Healing Following Trauma And Surgery
• Bone Stimulation– Ultrasound– Pulsed Magnetic Field– Implanted Direct Current
Bone Healing Following Trauma And Surgery
• Wound– Closed– Drains– Flaps– Open
• Packed• Wound Vac• Bead Pouch• Special Considerations
Rehabilitation FollowingBone Healing
• Rehabilitation is The Business of the Entire Medical Team
• Reduction and Immobilization May Be Unnecessary
• Rehabilitation is Always Essential– Preserve Function During Healing– Restore Function After Healing
Rehabilitation FollowingBone Healing
• Prime Goals of Rehabilitation– Maintain or Restore The Range of Motion of
Joints– Preserve Muscle Strength and Endurance– Enhance the Rate of Fracture Healing by
Activity– Early Return Function and Employment
Postoperative Rehabilitation
• Methods of Rehabilitation– Active Use– Active Exercises– Under Supervision of a Physical Therapist
• Phases– 1. Return to Range of Motion– 2. Regain Muscle Strength Strength– 3. Endurance and Functional Progression
Rehabilitation FollowingBone Healing
• Active Use– The Patient Must Continue to Use the Injured
Part as Naturally as Possible Within The Limitations Imposed by Necessary Treatment
– Rest May be Necessary for Days or Weeks
• Active Exercises– Muscles– Joints
Rehabilitation FollowingBone Healing
• Active Exercises– Muscles
• Isometric Exercise If Immobilization Present• Isotonic Exercise When Immobilization Removed
– Protected Range of Motion» Direction» Range
• Isokinetic Exercise
– Joints• Capsular Contracture• Capsular Laxity• Functional Instability
Rehabilitation FollowingBone Healing
• Active Exercises– Edema Control– Disuse Atrophy– Sympathetic Nervous System Dysfunction
• Complex Regional Pain Disorder• Reflex Sympathetic Dystrophy• Causalgia
Rehabilitation FollowingBone Healing
• Active Exercises– Contralateral Limb Rehabilitation– Joint Stabilization– Joint Range of Motion– Muscle Strength– Balance Sense-Proprioception– Endurance– Activity Specific Reeducation
• Continuous Passive Motion
Rehabilitation FollowingBone Healing
• Gait Training– Wheelchair– Scooters– Walker– Crutches– Cane
• Gait Patterns
• Weight Bearing Status
Rehabilitation FollowingBone Healing
• Modalities– Heat
• Hot Packs• Ultrasound• Diathermy• Whirlpool
– Cold– Contrast Baths
Rehabilitation FollowingBone Healing
• Modalities– E-Stim– TENS– Microcurrent
• Massage
• Orthotics
Where Surgical Services Provided: Outpatient vs. Inpatient
• In Community (On Field)• Emergency Room
– Monitored Bed
• Hospital Surgical Suite• Bedside• Hospital Based Outpatient Office Center• Free Standing Ambulatory Surgery Center• Private In-Office Procedure
Arthroscopic and Endoscopic Procedures
• Arthroscopy– Hip– Knee– Ankle– Subtalar Joint– Great Toe MPJ
Arthroscopic and Endoscopic Procedures
• Endoscopy– Spine– Carpal Tunnel– Plantar Fascia– Morton’s Neuroma
Upper Extremity
Shoulder
• Fracture/ Dislocation– Clavicle/ A-C Joint– Glenohumeral Joint– Surgical Neck Humerus
• Repair/ Reconstruction– Acromio-clavicular Joint– Rotator Cuff
• Impingement• Tear
Shoulder
• Repair/ Reconstruction– Glenohumeral Joint
• Capsule• Labrum• Long Head Biceps
• Prosthesis– Hemiarthroplasy– Total Shoulder Arthroplasty
Shoulder
• First 3 Weeks After Surgery– Control Postoperative Inflammation and Pain– Protect Healing Soft Tissue– Minimize Effects of Immobilization
• Cervical, Elbow and Wrist Motion
• 3 to 6 Weeks After Surgery– Muscle Strengthening
• Scapular Stabilizers• Rotator Cuff
Shoulder
• 9 to 12 Weeks After Surgery– Enhance Kinesthesia and Joint Position
Sense– Build Endurance– Strength Scapular Stabilizers– Work or Sports Specific Tasks
Elbow
• Fracture/Dislocation– Humerus– Radial Head and Neck– Olecranon– Elbow Dislocation
• Repair/ Reconstruction– Distal Biceps Tendon– Ulnar Collateral Ligament– Tennis/ Golfers Elbow (Epicondylitis)
Elbow & Wrist
• Nerve Decompression– Elbow
• Radial Nerve at Arcade of Froshe• Ulnar Nerve at Cubital Tunnel
– Wrist• Median Nerve at Carpal Tunnel• Ulnar Nerve in Guyon’s Canal
Elbow Rehabilitation
• 1-14 Days After Surgery– Achieve Range of Motion of Adjacent Joints
• Passive• Active• Active Assisted
– Promote Wound Healing– Control Edema– Control Pain– Retard Muscle Atrophy
Elbow Rehabilitation
• 15-45 Days After Surgery– Control Edema and Pain– Achieve Full Range of Motion-Passive– Maintain Full Range of Motion of Adjacent
Joints– Promote Mobility of Scar Tissue
Elbow Rehabilitation
• 4-6 Weeks After Surgery– Control Pain– Maintain Full Elbow and Forearm Range of
Motion– Strengthen Upper Extremity– Regain Normal Forearm Flexibility
Wrist and Hand
• Fracture/ Dislocation/ Sprain/ Strain– Wrist
• Colles• Smith• Barton’s• Scaphoid
– Hand• Metacarpal (Boxer, Bennett’s)• Finger (Crush, Mallet, Jersey, Volar Plate)
Hand and Wrist Rehabilitation
• Weeks 1-3: Inflammatory Phase– Decrease Pain– Manage Edema– Improve Active Range of Motion of Upper
Extremity– Initiate Self Management and Patient
Education
Hand and Wrist Rehabilitation
• Weeks 4-6: Proliferation Phase– Self Management of Symptoms– Return to Work Activities
• After 6 weeks Following Surgery– Remodeling and Maturation of Scar
Spine• Fracture/ Subluxation
– Osteoporotic Compression Fracture– Pars Fracture (Spondylolysis) – Spondylolithesis
• Reconstruction– Discectomy– Fusion– IDET/ Endoscopic Spine
Spine Rehabilitation
• Weeks 1-3: Protective Phase– Protect Surgical Site to Promote Wound
Healing– Maintain Nerve Root Mobility– Reduce Pain and Inflammation– Educate Patient
• Body Mechanics• ADL• Self Care
Spine Rehabilitation
• Weeks 4-6: Functional Recovery Phase– Educate in Neutral Spine Concept– Cardiovascular Conditioning– Increase Trunk Strength– Increase Soft Tissue Mobility– Increase Lower Extremity Flexibility &
Strength– Maintain Nerve Root Mobility
Spine Rehabilitation
• Weeks 7-12: Resistive Training Phase– Independent in ADL and Self Care– Increase Activity Tolerance– Return to Normal Functional Level
Lower Extremity
Pelvis and Hip
• Fracture/Dislocation– Pelvis
• Ring• Acetabulum
– Hip• Intracapsular• Extracapsular
Hip and Knee
• Joint Reconstruction– Osteotomy– Fusion
• Joint Arthroplasty– Resection (Girdlestone)– Resurfacing– Hemiarthroplasty– Total Joint Replacement
Hip and Pelvis Rehabilitation
• Preoperative Training – Gait Training– Transfer Techniques
Hip and Pelvis Rehabilitation
• Postoperative Days 1-2– Prevent Complications– Increase Muscle Contraction and Control– Positioning Precautions– Up in Chair– Transfers– Ambulation
Hip and Pelvis Rehabilitation
• Postoperative Days 3-7– Prevent Complications– Positioning Precautions– Promote Transfers– Gait Independence– Discharge to Rehab or Home
Hip and Pelvis Rehabilitation
• Postoperative Weeks 1-6– Positioning Precautions– Improve Hip & Lower Extremity
• ROM• Strength• Balance
Hip and Pelvis Rehabilitation
• Postoperative Weeks 1-6– Increase Independence In
• Transfers• Gait
– Plan Return to • Home• Work• Previous Activities
Knee
• Fracture– Supracondylar Femur– Patella– Tibial Plateau
Knee
• Acute Dislocation/ Sprain/ Strain– Ligament
• Collateral• Cruciate
– Meniscus
• Degenerative– Meniscus– Patello-Femoral– Femoral/ Tibial
Knee Rehabilitation
• Preoperative Training – Gait Training– Attempt to Resolve
• Inflammation• Swelling• Pain
– Exercise to Regain• Rom• Strength• Balance Sense (Proprioception)
Knee Rehabilitation
• Acute Phase: Post-op 1-2 Weeks– Decrease Pain– Manage Edema– Increase Weight Bearing Activities– Facilitate Quad and Hamstring Contraction– Full Knee Extension– Increase Passive & Active ROM– Joint Mobilization
Knee Rehabilitation
• Acute Phase: Post-op 1-2 Weeks– Decrease Pain– Manage Edema– Increase Weight Bearing Activities– Facilitate Quad and Hamstring Contraction– Full Knee Extension– Increase Passive & Active ROM– Joint Mobilization
Knee Rehabilitation
• Subacute Phase: Post-op 3-4 Weeks– Decrease Pain– Manage Edema– Increase Weight Bearing Activities
• Stand to Sit
– Facilitate Quad and Hamstring Contraction– Full Knee Extension– Increase Active ROM– Joint Mobilization and Stabilization
Knee Rehabilitation
• Advanced Phase: Post-op 5-6 Weeks– Decrease Pain– Manage Edema– Increase Weight Bearing Activities
• Gait Training • Reduce Reliance on Ambulatory Aids
– Joint Mobilization and Stabilization– Progress Exercise Program
Knee Rehabilitation
• Upgrade Phase: Post-op >7 Weeks– Progress Exercise Program– Return to Activities– Ongoing Training Program
Foot and Ankle
• Trauma (Acute and Overuse)– Sprains and Strains
• Achilles• Lateral Ankle• Plantar Fascia
Foot and Ankle
• Fractures/ Dislocations• Ankle• Os Calcis• 5th Metatarsal Base• Lisfrac Fracture/Dislocation• Metatarsal Stress Fracture• Toe crush and fracture
Foot and Ankle Rehabilitation
• Post-op Initial Immobilization 4-6 Weeks– Gait Training– Contralateral Lower Extremity Rehab– Cardiovascular Training
Foot and Ankle Rehabilitation
• Phase 1 Rehab 2-6 weeks Post-op– Decrease Pain & Swelling– Restore Joint and Soft Tissue Mobility– Protected ROM
• Bracing
– Increase Strength in Lower Extremity– Increase Proprioception– Normalize Gait– Maintain Cardiovascular Fitness– Patient Education
Foot and Ankle Rehabilitation
• Phase 2 Rehab 6-8 weeks Post-op– Decrease Pain & Swelling– Restore Normal Joint ROM– Increase Strength in Lower Extremity
• Intrinsic and Extrinsic Foot & Ankle Muscles
– Increase Proprioception– Normalize Gait– Maintain Cardiovascular Fitness– Bracing
Foot and Ankle Rehabilitation
• Phase 3 Rehab 8-10 weeks Post-op– Prevent Pain & Swelling– Maintain Normal Joint ROM
• Mobilization• Passive Stretching
– Increase Strength and Endurance– Increase Balance & Proprioception– Focus Training on Return to Work and Sports– Bracing/ Orthotics
Foot and Ankle Rehabilitation
• Phase 4 Rehab >10 weeks Post-op– Maintain Joint ROM– Increase Strength and Endurance– Increase Balance & Proprioception– Return to Work & Sports Activities– Bracing/ Orthotics
Thank You