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MSPT I > COMPS:PT Mgmt of Pts w/ Hip and Knee OA--ZENI > Flashcards

COMPS:PT Mgmt of Pts w/ Hip and Knee OA--ZENI Flashcards

1
Q

OA is a ________ process

*NOT just wear and tear

A

Disease process

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2
Q

Defining Knee OA radiographs

Kellgren Lawrence Scores*

4 Grades

A

Graded 0 (none)

to

Grade 4 (severe)

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3
Q

Defining Knee OA

Kellgren-Lawrence Scores

Grade 0 (NONE)

A
  • Grade 0== NONE
    • definite absence of x-ray changes of OA
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4
Q

Defining Knee OA

Kellgren Lawrence scores

Grade 1 (Doubtful)

A
  • Grade 1 == doubtful
    • doubtful jt space narrowing and possible osteophytic lipping
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5
Q

Defining knee OA

Kellgren Lawrence Scores

Grade 2 (minimal)

A
  • Grade 2== minimal
    • definite osteophytes and possible jt space narrowing
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6
Q

Defining Knee OA

Kellgren Lawrence Scores

Grade 3 (Moderate)

A
  • Grade 3== moderate
    • moderate multiple osteophytes, definite narrowing of jt space and some sclerosis and possible deformity of bone ends
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7
Q

Defining Knee OA

Kellgren Lawrence Scores

Grade 4 (severe)

A
  • Grade 4== severe
    • Large osteophytes, marked narrowing of jt space, severe sclerosis and definite deformity of bone ends
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8
Q

Uni or Multi-compartmental disease @ the Knee

A
  • Medial
  • Lateral
  • Patellofem

SEE pics !!!

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9
Q

Advanced OA Knee

A

see pics

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10
Q

Defining Knee OA–Clinical Presentation

The Cardinal Signs

A

Age

Brief AM stiffness

Crepitus

Tenderness

Bony abnorms

NO warmth

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11
Q

Defining Knee OA–clinical present.

ACR Clinical definition

PAIN IN THE KNEE PLUS @ least 3 of the following:

A
  • Pain in the knee + 3 of following:
    • >50yo
    • <30 mins morning stiff.
    • crepitus w/ active motion
    • bony tenderness
    • bony enlargement
    • NO palpable warmth of synovium

NOTE: some studies show that these criteria reflect later stage disease and may not capture indiv’s w/ EARLY or MILD OA****

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12
Q

2 scales common in grading HIP OA

A
  1. KL Scale
  2. Tönnis Classification

see below for Tönnis

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13
Q

In a nutshell….. Tönnis Scale of HIP OA

A
  • 0
    • NONE
  • 1
    • mild
    • minor
    • No or minor
  • 2
    • moderate
    • moderate
    • moderate
  • 3
    • Severe
    • Severe
    • Severe
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14
Q

Defining HIP OA—clinical present:

Very high likelihood of Hip OA w/ 4 out of these 5 present:

A
  • Self-reported squatting as an aggravating factor
  • Active hip flexion causing LATERAL hip pain
  • Scour test w/ ADD. causing lateral hip OR groin pain
  • Active hip EXT causing pain
  • passive IR of LESS THAN or EQUAL to 25deg
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15
Q

OA is more than just cartilage loss

Jt swelling, bursa inflammation, changes to synovial fluid and jt capsule

A

see pics

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16
Q

OA is more than just cartilage loss

Mm atrophy, weakness, morphological changes

ex. fat permeating into jt

A

see pics

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17
Q

OA more than just cartilage loss

Cartilage deterioration (X-ray) and Morphological changes (MRI)

A

see pics

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18
Q

OA more than just cartilage loss

Osteophytes, thickening of subchondral bone, Bone Marrow lesions (MRI)

A

see pics

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19
Q

OA cannot _________

A

CANNOT be considered a disease of ONLY the articular cartilage!!!

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20
Q

Activation Deficit

Prominantly in OA

A
  • Diff AFTER electrical stim vs. what pt can do volitionally
  • neurological system cannot fullt activate ALL mm’s in a region

**Quadriceps Lag**

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21
Q

Mvmt patterns and motor control also change

Asymmetrical and abnorm biomechanics

Favoring the Good side

For Knee…

A

Stiff legged gait pattern

CARDINAL SIGN

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22
Q

Mvmt patterns and motor control also change

Asymmetrical and abnorm biomechanics

Favoring the Good side

The Hip….

A

Lateral and forward trunk lean TOWARD GOOD SIDE

DECd hip EXT ROM

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23
Q

CARDINAL SIGN HIP OA

A

Lat. trunk lean w/ walking TOWARDS AFFECTED SIDE

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24
Q

Mvmt patterns and motor control changes

Knee OA

co-contraction vs. muscle timing

A

INC’D co-contraction

ALTERED mm timing

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25
Q

Alignment changes, Jt Load changes

Knee OA

What is the pattern?

A

Malalignment==> Altered Loading==>Cartilage Loss==>Malalignment

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26
Q

Valgus vs. Neutral vs. Varus Radiographs

A
  • More cartilage loss==
    • ​worse alignment becomes
  • Worse alignment becomes==
    • ​more abnormal forces become
  • More abnormal forces become==
    • ​more cartilage is lost
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27
Q

Phys. impairments lead to _________

A

Functional Deficits

  • Ex. OA vs. Control group
    • TESTED:
      • Age
      • KOS-ADLS
      • TUG
      • SCT
      • Quad Strength (Op)
    • Nearly 50% reduction in KOS, TUG, SCT and Quad strength
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28
Q

In a nutshell….

The Cycle

Injury (ACL, fx), Bony deformity, Weakness, Unfortunate genetics ======>

A
  • Joint pain==> Decd phys act==> muscle weakness==> abnormal biomechanics==> cartilage loss and jt laxity==> Joint pain
  • Over the span of 5-20 yrs
  • Drs usually say
    • ​”come back when nothing else works and you can’t take pain anymore”
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29
Q

Primary OA

*usually older pop.

A
  • Disease is of idiopathic origin (no known cause)
  • Usually affects mult. joints
  • Elderly pop
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30
Q

Secondary OA

*monoarticular

A
  • Monoarticular
  • develops as result of defined disorder affecting jt articular surface (ex. trauma) or from abnormalities of joint
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31
Q

Secondary OA

Hip

A
  • Dysplasia
  • SCFE
  • Fx
  • FAI
  • Avascular necrosis
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32
Q

Secondary OA

Knee

A
  • Trauma
    • ​chondral lesions
  • ACL injury
  • Fx’s
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33
Q

Radiographic DOES NOT always match sx’s

Do NOT emphasize structure

Emphasize Function!!

A
  • DO NOT SAY:
    • Bone-on-bone
    • end-stage
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34
Q

Certain descriptors of OA make pts feel:

A
  • Jt is susceptible to damage
  • OA will inevitably get WORSE
  • TKA is only option and cond. is irreversible
  • Doing more exercise or activity will damage the joint

ALL WRONG!!!

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35
Q

OA is a serious cond. and needs to be approp. mg’d, NOT just put off until TKA

A

INCd risk of CV disorders, morbidity, mortality

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36
Q

Key Points:

OA Patho.

A
  • OA==more than just a disease of cartilage
  • OA is a chronic cond and must be tx as such
  • Pts. develop asymmetrical mvmt patterns
    • ​Reduce demand on operated limb and INC reliance on the non-affected side
    • ​Result of pain, weakness, laxity
      • which came first???
  • Pts w/ hip and knee OA develop behaviors in response to PAIN
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37
Q

Risk factors for OA development and progression

What are some ex’s?

A

Phys activity and risk

ROM deficits

Muscle control deficits

Dynamic frontal plane alignment

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38
Q

Injury Type vs. Risk of Developing OA compared to an uninjured group

Basically…. based off of previous injury type, what is your risk (likelihood) of developing OA?

A

see pics

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39
Q

Phys activity and risk for Knee OA

what factors INC risk for OA?

A
  • Previous injury
    • ​see previous chart
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40
Q

Phys activity and risk for OA

Not all meniscal injuries have same risk!

A
  • Medial extrusion, complex tears, large radial involvement were more common in those who develop OA***
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41
Q

Sports and risk for OA

Sports are generally NOT a risk factor

Exceptions:

A
  • Soccer
    • 3.5x INC risk
  • Elite lvl long dist running
    • 3.3x INC risk
  • Competitive wt lifting
    • 6.9x INC risk
  • Wrestling
    • 3.8x INC risk
  • For those w/out history of injury– soccer and Am football had INCd risk of OA
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42
Q

Vocation and risk for OA

A
  • Kneeling or squatting
    • 2-7x inc risk
  • Heavy lifting
    • 1.9-7.31x INC risk for Knee
    • 2.46x INC risk for Hip
    • ​Dose resp to freq of lifting OR total wt lifted
  • Heavy lifting + Kneeling or Squatting
    • 2.4 lifting alone, 3.4 w/ kneeling or squatting
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43
Q

Risk Factors for Hip OA

A

Modifiable

vs.

Structural or Congenital

see pics

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44
Q

Recreational risk factors for Hip OA

sports: Am football, track and field, racket sports

A

may INC RISK

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45
Q

Rec. risk factors for Hip OA

Freq stair climbing

A

May INC RISK

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46
Q

Rec. risk factors for Hip OA

Recreational running

A

DOES NOT INC RISK

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47
Q

REC. risk factors for Hip OA

Walking in lieu of running

A

DOES NOT DECREASE RISK

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48
Q

REC. risk factors for Hip OA

Leisure cycling or walking

A

DOES NOT INCREASE RISK

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49
Q

GREATEST modifiable risk factor for OA ====

A

BMI

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50
Q

BMI

Greatest modifiable risk factor for OA

sytemic inflammatory response also affecting joints

A
  • INCs risk for hand, hip, knee OA
    • ​Knee OA has greatest assoc w/ obesity
      • ​Overwt== 2x risk of healthy wt indiv.
      • Grade 1 obesity== 3.1x risk
      • Grade 2 obesity== 4.7x risk
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51
Q

BMI and OA

greatest modifiable risk factor

Losing wt has protective bennies of OA

A
  • Losing 5% of bw reduced risk of knee OA progress. by 50% in women
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52
Q

BMI

greatest modifiable risk factor for OA

Wt. loss in pts w/ OA improves biomechanics ***

A
  • Improvements in gait were NOT related to improvements in pain
53
Q

Predictors of OA–Alignment

Varus alignment

A

4x INC in odds of medial compartment OA progress.

54
Q

Predictors of OA–Alignment

Valgus alignment

A

5x INC in odds of Lateral compartment OA progress.

55
Q

Predictors of OA–Alignment

Higher BMI==STRONG risk factor for indiv’s w/ Varus OR Valgus alignment***

A
  • BMI was NOT risk factor in neutral align.
  • BMI WAS a risk in pts w/ moderate varus or valgus
56
Q

Predictors of OA – Thrust

Varus or Valgus Thrust

explain..

A
  • quick mvmt in frontal plane during wt. bearing portion of gait cycle
  • pt may have normal static alignment, but lack of motor control or laxity in jt leads to quick varus or valgus thrust during SLS
57
Q

Predictors of OA–Thrust

A
  • Varus or Valgus Thrust
    • 4x inc in risk overall
    • 3x INC in risk for pts w/ VARUS Alignment *****
58
Q

Why is alignment and thrust an issue?

A

Changes magnitude and location of force

59
Q

Adduction Moment @ the hip

A
  • conceptualized as distance b/w GRF vector and joint axis
    • ​Greater dist==greater moment
    • Greater moment==greater loading
  • correlated to Medial Compart. jt loading
  • **predictive of Future OA progression**

M=FxD

60
Q

Adduction Moment

How can we reduce the distance?

A
  • Moving axis CLOSER to GRF
    • ​Unloader bracing
    • Medial thrust modified gait
  • Moving GRF vector CLOSER to axis of the knee
    • ​Lateral trunk lean modified gait
  • Combo of the two
    • ​heel wedges
    • Gait retraining
61
Q

Biomechanics and knee OA

more than just static alignment

A

Small changes in frontal plane can influence OA incidence and progress.

62
Q

Biomechanics and knee OA

Biomech-based interventions should do what?

A
  • REDUCE abnorm frontal plane motion
    • stop the thrust
  • Put knee in NEUTRAL pos.
    • maintain alignment
  • Normalize shock-absorb feature of quads
    • no stiff-legged gait patterns
  • REDUCE overloading med or lat comparts
    • ​reduce ADD moment
63
Q

Biomechanics and Knee OA

addressing phys. impairments (ROM, weakness, proprio) shoud NOT exacerbate abnormal biomechanics

Don’t make it worse!!!

A
  • Ex.
    • do NOT solely train ABD’s in pt who is varus or has Varus Thrust
64
Q

Biomech. Screening for pts w/ OA

Includes what?

A

MSK Exam (strength, ROM, alignment, effusion, function)

Tools to assess movement dysfunction

65
Q

MSK Assessment

A
  • ROM
    • active/passive
  • Laxity
  • Strength
  • Special tests for LE alignment
66
Q

Static and Dynamic Visual Movement Assess.

2 Components

A
  1. Static Postural/Alignment
  2. Movement Assessment
67
Q

Static and Dynamic Visual Movement Assess.

Static Postural/Alignment

A
  • Weight bearing
68
Q

Static and Dynamic Visual Movement Assess

Movement Assess

A
  • Recorded if poss. to slow down and stop video
  • Try and pick specific instances of gait cycle AND specific joint, then REPEAT
    • Gross abnorms
    • Gross quality of mvmt
    • Gross asymmetries
69
Q

Static and Dynamic Visual Movement Assessment

A

see pics

Static postural/alignment

vs.

Movement assess.

70
Q

Some ex’s of Interventions for Pts w/ OA

A

Agility + Perturbation

Gait Retraining

Passive Devices

Monitoring response to tx

71
Q

Interventions for OA

Address______

Address______

Address______

Normalize_____

A
  • Address phys impairments
  • Address behavioral changes
  • Address dynamic and static malalignment issues
    • Knee OA
  • Normalize biomechanics and reduce biomech. risks
72
Q

Interventions for OA

Addressing phys impairs

A

weakness, ROM (jt contractures), instability

73
Q

Interventions

Addressing behavioral changes

A

Encourage physical activity

**6000 steps/day shoud be target to reduce functional decline

Weight loss

***IDEA study–> lose wt==less arthritis progress.

74
Q

Interventions

Address dynamic and static malalignment issues in Knee OA

A

Bracing

NMSK training

75
Q

Interventions

Normalize biomechanics and reduce biomech. risks

A

Gait retrain.

Agility and ge. mvmt training

76
Q

STRONG evidence for all these interventions and Knee OA

A
  • exercise
  • wt loss
  • self-efficacy
  • self-mgmt programs
  • tai chi
  • cane use
  • tib/fib bracing for tib/fib knee OA
  • NSAIDs for Knee OA—topical
  • oral NSAIDs
  • intraarticular glucocorticoid injections for knee OA
77
Q

Knee OA interventions

Conditional Use of these….

A
  • Balance ex
  • yoga
  • CBT (cognitive behavioral therapy)
  • Patellofem. bracing for patellofem knee OA
  • acupuncture
  • thermal modals
  • radiofreq. ablation for knee OA
78
Q

Table: Recommendations for phsyical, psychosocial, and mind-body approaches for the mgmt of osteoarthritis

79
Q

Knee strength and ADL training VERSUS Knee strength and ADL training + Knee Stabilization

  • RCT of 159 pts w/ knee OA
    • ​pts had knee instability verified w/ self-reported buckling OR giving way OR biomech. assessed instability of frontal plane laxity OR poor proprio
    • Training focused on perception of knee position and motion to improve proprioceptive accuracy, and on maint. of static or dynamic control of the knee to limit consequences of high laxity
      • EX. lunging w/ resistance and keeping neutral knee (no valgus/varus)
    • 12wks, 2x/wk, 60mins, Progressive training
A
  • RESULTS:
    • ​IMPROVEMENT REGARDLESS OF GROUP ASSIGN. BUT…..
    • Pts w/ WEAKER Muscles responded better to the Control Intervention (Strength Training only)
    • Pts w/ STRONGER Muscles responded better to the Knee Stabilization Intervention (bc had strength/muscle to perform better)
  • NOTE: Adding knee stab. into treatment program may only be beneficial to indiv’s who DO NOT have substantial LE mm weakness
80
Q

Passive Devices to control biomechanics in OA

examples?

A
  1. variable stiffness shoe
  2. contralateral cane
  3. bilateral hiking post
  4. unloader bracing
  5. bracing w/ extension assistance
81
Q

Passive devices

Variable stiffness shoe

A
  • Reduces ADD. moment during tasks
    • protects medial compartment in knee
82
Q

Contralateral Cane especially good for….

A

Hip OA

*good evidence to support*

83
Q

Bilateral hiking poles and OA???

A

Limtd evidence

84
Q

Unloader brace and OA

A

Evidence to support use

Moves knee back to neutral pos.

85
Q

PTs should NOT rely on passive devices alone

A
  • Pts need to be aware and work on improving sagittal plane motion
    • ​*part. @ IC, LR, MSt
  • Often the passive device is NOT enough and MAY req. add. relearning strategies
  • Passive + Motor Retraining + Therapeutric Exercise!!!

NOTE: despite knee brace w/ EXT assist—> pt will still use flexed and stiff gait pattern

86
Q

passive+motor training should match the pts what?

A

Deficits!!!

  • Ex. if active terminal knee deficits are present
    • pt has normal ROM, but lands w/ flexed knee
87
Q

Passive + motor retraining should match pts what?

diff. example…

A

Deficits!!!

  • If pt has varus thrust during WB–> use targeted training to reinforce normal mvmts during WB activities
    • Training and position should match WHEN deficits occur during gait
88
Q

Always start _______ and ________

A

start simple and progress

89
Q

How do you monitor tolerance of progression?

2 ways:

A
    1. monitor signs of jt irritation or injury
      * ​Swelling
      • Effusion test==indicates intra-art. prob
      • tenderness to palpation
    1. monitor Pt reported outcomes
      * ​Pain+soreness
      * Instability
      * Stiffness
90
Q

Effusion Testing

“Sweep Test”

A

Stroke UP Medially

Stroke DOWN Laterally

91
Q

Quantifying Effusion

Effusion Grade + Test Result

A
  • Zero
    • ​NO wave produced w/ downstroke (medial)
  • Trace
    • ​SMALL wave on medial side w/ DOWNstroke
  • 1+
    • ​LG bulge on medial side w/ downstroke
  • 2+
    • ​Effusion spont. returns after upstroke
      • ​NO downstroke needed****
  • 3+
    • ​SO MUCH FLUID that it cannot be moved out of medial aspect of knee
92
Q

When to Slow Progression or Hold Tx

w/ Effusion grades

A
  • pts should NOT be progressed in ex. program when effusion is 2+ or more
  • If 2+ persists despite effusion tx’s —-> contact MD
    • ​Tx ex’s
      • ​compress wrap, effusion massage, limb elevation, reduced WB/activity
  • ANY drastic change of 2 grades OR appearance of effusion when it was ABSENT
    • ​DEC act. to lvl prior to effusion change
      • ​GRADUALLY reintroduce act.
93
Q

Soreness Rules of Exercise Progression

Joint Pain

94
Q

TKA Process

95
Q

THA Process and Approaches

A
  • Medial
  • Anterior
  • Anterolateral
  • Direct Lateral
  • Posterior
96
Q

THA Precautions

Posterior Approach

A
  • Do NOT bend forward past 90deg
  • Do NOT cross your legs
  • Do NOT turn toes inward and Do NOT twist
  • Do NOT turn knees inward or together
97
Q

Concerns EARLY after SX

TKA and THA

A

infection

DVT and PE

Wound dehiscence (tearing apart)

98
Q

Concerns EARLY after SX

THA

A

Hip precautions!!!

Dislocation

Nerve issues (part. sciatic or femoral)

99
Q

Concerns EARLY after SX

TKA

A

Nerve issues (part. peroneal bc wraps around Fibular Head)

100
Q

Resolution of pain and cartilage defects does NOT resolve all pt’s impairments

T/F???

A

TRUE!!!

  • Pain resolves quickly after TKA
    • often not barrier after 6wks
  • OA==Chronic disease
    • dx’d decades before TKA
  • Mvmt patterns and NMSK control have “NEW” normal
    • pts cont to rely on “good” leg
    • many pts AFTER TKA walk w/ reduced knee flex==> Stiff-knee gait pattern
101
Q

Resolution of pain and cartilage defects does NOT resolve all pt’s impairments

A
  • TKA does NOT change pt behavior or phys activity
  • Even AFTER rehab, strength does NOT exceed pre-op values******
  • Functional tests: important to measure pt recovery BUT do NOT provide info on biomechanics
    • ​TUG
    • 6MW
102
Q

Pre-hab and Education

3 Outcomes:

A
  • Expectation setting
    • ​Respect timeline, pain, hospital procedures
  • Instruction on future HEP
    • ​Practice exercises***
  • Environment set-up/Safety
    • ​raised toilet seat/shower chair
    • assist @ home
    • HIP PRECAUTIONS***

NOTE: Better you go IN===Better you come OUT (esp first week or 2)

103
Q

Prehab consists of:

A

Exercises for ROM, strength, endurance

104
Q

Stage 1:

Immediate Post-OP

Days 0-3

A
  • ​Safety, ADs, Gait
    • ​Hip Precautions
  • Education
    • ​HEP
    • Infection
  • Determine discharge Location
    • ​Home vs. Rehab
105
Q

Stage 1:

Early Acute

Day 0–Week 2

A
  • Attenuate swelling and prevent strength loss
  • GENTLE ROM
106
Q

Attenuating Swelling

Methods

Manual Lymph Drainage Massage

A

10 min daily @ end of the day

Pts measured swelling pre/post

107
Q

Swelling

HEP

*First 2 weeks

A 
# * Toe curling/Ankle DF **1 min ea. hour**
* Choose 1 of 4 additional ex's **5x/day**

***1 min of Ankle Pumps INCs Venous Return 22% for 30mins

108
Q

Physical Impairments during Early Stages post-op can include:

A
  • ROM
    • ​do NOT “overdo it”
    • ID pts @ risk for arthrofibrosis
  • Strength (from day 1!!!!)
    • ​NMES
      • lg pads
      • MAX tolerable intensity
      • Active mm activation ON TOP OF NMES stimulated mm contraction
      • provide feedback
  • Maximize STRENGTH AND ACTIVATION!!!
109
Q

Addressing Activation Deficits:

A
  • Strengh highly correlated w/ Function
  • Even 1yr post TKA pts strength SAME as pre-op values
  • Quad focus
    • ​also hips, lower leg mm’s
110
Q

Addressing Activation Deficits:

Multiple factors contribute to mm weakness:

A
  • Activation deficits
  • Disuse atrophy
  • Morphological changes
  • Changes in afferents/proprioception

**NOTE: contribution of hip ABD strength to phys function in pts w/ TKA

111
Q

Stage 1 POST-OP

Goals/Documentation

A
  • Realistic pt-specific goals
  • Doc. pt activity @ weekly sessions
    • ​obj. measures
    • steps/day, activity counts, mins of ex, HR based on activity zones
  • INC activity target on weekly basis
  • % based INCs
112
Q

Stage 1 & 2 Combined

Progressive Strengthening ==ESSENTIAL

HEP and Clinic

KEY WORD: ESSENTIAL !!!!!

A

Focus on Quality and Control of mvmts

113
Q

Stage 1 and Beyond

Movement Retraining

A

ex. Tapered mirror/visual feedback during gait

*listening for symmetrical footstrikes

114
Q

Movement retraining for gait may NOT carry over to other activities

meaning….

A

End phases of pt rehab should focus on pt-specific goals/whatever it is they want to get back to!!!!

115
Q

Running Progression

Keep in mind you are progressing pt in TINY INCREMENTS

116
Q

Recommendations for Athletic Activity after TJA???

Discouraged vs. Occasional vs. Unlimited

117
Q

Word of Caution on Recommended Activities

Unlimited

A
  • Swimming
  • Walking over EVEN ground
  • Golf
  • Cycling over EVEN terrain
  • Walking stairs
118
Q

Word of Caution on Recommended Activities

NOT Recommended or NO Consensus

Based on OPINION

A
  • Climbing
  • Skiing groomed trails
  • Off road cycling
  • Singles tennis
  • Jogging
  • Skiing diff. trails
  • Sprinting
119
Q

CPG for Pts After TKA

Intervention Outline:

A
  • Continuous Passive Mvmt Device (CPM) for mobilization
  • NMES
  • Phys Activity
  • Cryotherapy
  • Resist. and Int. of Strengthening Ex.
  • Knee Flex during rest for swelling
  • Motor Function Training
    • balance, walking, mvmt, symmetry
  • Post-op Knee ROM ex’s
120
Q

CPM Device for Mobilization:

Recommendation:

PTs should NOT USE CPMs for pts who have undergone primary, uncomp TKA

A

Evidence Quality: HIGH

Recommendation Strength: MODERATE

*There is INCd risk, harm, or cost

*Positive, sig. results were contradicted by high quality studies

121
Q

Cryotherapy

Recommendation:

PTs SHOULD TEACH and ENCOURAGE its use for early post-op pain mgmt

A

Evidence Quality: HIGH

Recommendation Strength: MODERATE

**Insuff. evidence to support a specific app. method, aplication time frame, or days post-sx to continue cryo.

122
Q

Knee Flexion During Rest for Swelling

Recommendation:

PTs MAY teach pts to pos. the operated knee in SOME DEGREE of FLEX while resting during first week

***Long term effect on ROM???

A

Evidence Quality: HIGH

Recommendation Strength: WEAK

Potential Unmeasured Risk: Limtd Knee EXT

***This can reduce immediate post-op blood loss and swelling, as well as improve short term flexion ROM

123
Q

Physical Activity CPG

Recommendation:

PTs SHOULD DEVELOP and Teach appropriate progression of physical act, based on safety, functional tolerance, and physiological response

A

Evidence Quailty: INSUFF.

Recommendation Strength: BEST PRACTICE

**This includes WB, balance, flex. activities which are shown to improve variety of outcomes; 42% of pts did NOT meet recommended lvls 1 yr after TKA ***

124
Q

Motor Function Training

Balance, Walking, Mvmt Symmetry

Recommendation:

PTs SHOULD INCLUDE motor function training (balance, walking, mvmt symmetry w/ visual feedback)

A

Evidence Quality: HIGH

Recommendation Strength: MODERATE

**Improves balance, walking function, activities, participation

125
Q

Post-Op Knee ROM Exercise

Recommendation:

PTs SHOULD ENCOURAGE and teach pts to implement passive, active assist, and active ROM ex’s for the involved knee following TKA

A

Evidence Quality: INSUFF. (Current Standard)

Recommendation Strength: BEST PRACTICE

**INCd range and function

**DECd complications

126
Q

NMES

Recommendation:

PTs SHOULD USE NMES to improve quad strength, gait training, performance-based outcomes, and pt reported outcomes

A

Evidence Quality: HIGH

Recommendation Strength: MODERATE

**Earlier NMES and more Frequent (mult x/day) app w/ longer cumulative time @ max pt tolerance improved outcomes

**Apply for min. of 3wks

127
Q

Resistance and Intensity of Strengthening Exercise

Recommendation:

PTs SHOULD design, implement, teach and progress the pt in high-intensity strength training and ex. programs w/in first week after Sx

A

Evidence Quality: HIGH

Recommendation Strength: MODERATE

**Improves function, strength, balance, ROM

**HIGH and LOW intensity–> equally safe

MSPT I (10 decks)

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