NPTE FF: REHAB PROTOCOLS Flashcards
Hip Arthroplasty
ANTERIOR/ANTEROLATERAL THA
Dislocation precautions to AVOID:
- AVOID hip flexion > 90degs
- AVOID hip ext, add, ER past neutral
- AVOID combo of abd/flex/ER
Overall LOWER dislocation risk vs Posterior approach
Hip Arthroplasty
POSTERIOR/POSTEROLATERAL THA
Dislocation precautions to AVOID:
- AVOID add past neutral
- AVOID hip IR past neutral
- AVOID hip flex >90 degs
HIGHEST risk for dislocation
Hip Arthroplasty Protocols
Phase I: MAX PROTECTION
Remember your “Rule of 6”
- Education to pt/caregiver to avoid precautions
- Usually WBAT
- Ankle pumps prevent DVT
- Monitor for possible infx
- Maximimze functional mobility (bed mob, transfer training, approp trunk mechanics when sit to stand to avoid violating precautions
- Strengthen UEs
- Avoid hip flex contracture**
THA Protocols
Stage 2: Typ begins 4-6wks post-op
- Regain strenght/mm endurance
- Strengthen hip Abd’s and ER’s
- Improve CV/Pulm endurance
- Restore ROM w/in dislocation precautions
- Improve postural stab, balance, gait
THA Protocols
Stage 3: Begins around 12wks post-op
- Extended rehab/modify activities if necessary
- Ensure good strenght of hip Abd’s and ERs (mentioned in Stage 2 also
- RTS and higher lvl acts
Total Knee Arthro (TKA)
FACTS:
- Relatively HIGH success rate
- LOWER risk vs THA
- Usually WBAT UNLESS cementless fixation used (uncommon)
TKA Protocols
Stage I: Weeks 1-4
- Control post-op swelling
- Minimize pain
- Control for DVT + infx
- Inc ROM to 0-90 (EXT PRIORITY!!)
- 3/5 to 4/5 quad strength
- Amb w/ or w/out AD
- Establish HEP**
Interventions:
- Ankle pumps, Quad/HS/Abd/Add setting, Gait, Patellar mobs
TKA Protocols
Stage II: Weeks 4-8
- Reduce swelling
- ROM 0-110
- 4/5 to 5/5 strength ALL LE mm’s
- UNrestricted ADL function
- Improve balance, functional mob, NMSK control
Interventions:
- Patellar mobs, LE stretching, CKC strength + PREs, Tibiofem jt mobs (if needed), proprio training, Aerobic ex (cycle, swim, walking)
TKA Protocols
Stage III: Week 8 onward
- Dev maintenance program
- Community amb
- Improve CV endurance/aerobic fitness
Interventions:
- SAME as stage II w/ progressions, Progress balance and adv’d functional acts, Ex’s specific to sport or higher lvl activity
Total Shoulder Arthro
All facts first…
MOST important thing to note w/ TSA is whether or not RTC repair performed
- If YES–> sling needed for @ least 4-6wks
- If NO–> sling weaned off same day as sx
2 most prominent forms of TSA:
1. INTACT RTC TSA
2. Reverse TSA
TSA
MOST important thing to note w/ TSA?
Whether or not RTC repair performed
- If YES, sling @ least 4-6wks
- If NO, sling weaned off same day as sx
2 most prominent forms of TSA?
- Intact RTC TSA
- Reverse TSA
INtact RTC TSA Protocols
Phase I: Weeks 0-4
- Elevation of arm restricted to < 120degs
- ER restricted < 30degs (w/ arm @ side)
- Grade I/II oscillations
- AROM scapular + elbow
PROM/AAROM - AAROM in supine first 3 weeks
- Week 4, transition to sitting/standing
- NO active IR for @ LEAST 6wks–protects subscap repair
- Pendulums + LIGHT NWB isometrics of shoulder mm’s in scapular plane
INtact RTC TSA Protocols
Phase II: Weeks 4-12
- Continue AROM
- NO GH EXT past neutral (up to 6wks)
- Gradually inc GH rotation
- GENTLE stretching after 6-8wks
- Improve function of RTC and scap stabilizers
- SUBmax iso’s of GH mm’s w/ LIGHT WB thru UE
- Delay resisted rotation for several weeks (if NON-intact RTC)
- Progress to low-resistance dynamic strength
INtact RTC TSA Protocols
Phase III: 12+ weeks
- Combined add/IR/Ext permitted
- Progress end range self stretches
- Progressive resistive ex’s in functional patterns
- CKC stabilization
Reverse TSA Protocols
Phase I: 0-6wks
- ABD splint (24hrs/day for >3 but < 6 wks
- NO GH EXT or IR past neutral
- 0-20 ER and up to 90-120 elevation in scap plane
Once immobilizer removed:
- Grade I/II oscillations
- AROM scapula+elbow
- Pendulums
- PROM only of GH jt
- Only LIGHT, NWB iso’s of scap stabilizers and deltoid
Reverse TSA Protocols
Phase II: 6-12wks
- NO GH EXT/IR past neutral
- 0-20 ER and up to 90-120 arm elevation in scap plane
- INC PROM while observing phase I stuff
- AAROM (begin in supine, progress to sitting)
- Improve function deltoid/scap stabilizers
- SUBmax iso’s (NWB)
- Delay resisted rotation for several weeks
- Progress to low-resistance, dynamic strength of elbow/wrist towards end of Phase II
Reverse TSA Protocols
Phase III: Weeks 12+
- GENTLE stretch w/in motion restrictions
- Begin CKC stabilization
- Progress to UE PREs in functional patterns
RTC Repair
All protocols
- Passive OR assisted ROM w/in SAFE and PAIN-FREE ranges based on surgeons report
- Only passive, NON-assisted ROM for 6-8wks after repair–> initially supine w/ progression to sit/standing
- MINIMIZE sup/ant translation of humeral head
- DO NOT ALLOW active shoulder flex/abduction until pt can lift arm w/out hiking shoulder
RTC Repair
Strengthening and Stretching
Strengthening:
- ISO scapular stabilizer strength w/ arm supported
- NO WB 6 wks
- DELAY dynamic strengthening for min of 8wks–> Avoid ER for supra/infra repairs–> Avoid IR for subscap repairs
Stretching:
- Avoid vigorous stretch, contract-relax, or grade III+ mobs @ least 6wks
- If supra/infra–> avoid IR stretch (bc this stretches ERs)
- If subscap–> avoid ER stretch (bc this stretches IRs)
SLAP Repair Protocols
SLAP Repair
- Limit passive OR assisted elevation to 60degs first 2wks and up to 90degs @3-4wks post-op
- Perform ONLY passive assisted rotation w/ shoulder in scap plane first 2wks–> ER neutral, IR to 45
- Wks 3-4–> progress ER to 30; IR to 60
- AVOID pos’s that create TENSION on Biceps!!–> elbow EXT w/ shoulder EXT first 4-6wks
- Postpone ACTIVE elbow flex for 6wks and resisted biceps ex’s until 8-12wks
- AVOID pos’s of Abd+ER–> stresses biceps insertion on to glenoid**
Wrist-Flexor Tendon Repair
Wrist-Flexion Tendon Repair
Wrist immobilized after sx up to 5d, unless prolonged immob needed
- Zone I, II, III repair immob: 10-45degs of wrist flexion AND from 40-70degs MCP flexion–> IPJs in FULL but comfy EXT
Exercises to maintain tendon-gliding and PREVENT adhesions:
- EARLY, controlled passive motion
- EARLY, controlled active motion
Wrist-Flexor Tendon Repair
Phase I: Up to 3-5wks
- PASSIVE MCP, PIP, DIP flex/ext of ea indiv jt
- Place & hold ex’s
- MIN-tension, short-arc motion
Wrist-Flexor Tendon Repair
Phase II: 4-8wks
- Aim to safely inc stress on repaired tendon & achieve FULL ACTIVE flex/ext of wrist & glides of tendons
- Place-and-hold ex’s w/ gradual inc in tension
- Active ROM: Flex/ext of IPJs w/ MCPs flexed, MCP flexion/ext w/ IPJs relaxed, Active wrist flex/ext w/ fingers relaxed
- Initiate tendon-gliding and blocking ex’s @ 5-6wks
Wrist-Flexor Tendon Repair
Phase III: 8 wks
- Resistance ex’s for strength + endurance
- Dexterity ex’s
- Use of hand for LIGHT (1-2lbs) functional activities
Wrist- Extensor Tendon Repair
Immobilization protocol
Immob. in EXTd position. For zone III/IV repair–> PIP and sometimes DIP jts placed in EXT; zone V/VI repair–> wrist held in 30deg EXT and MCPJs in 30-45degs Flexion
Wrist- Extensor Tendon Repair
Early Controlled Active Motion Approach
For Central Slip Tear
- Ex. performed w/ finger splint
Ex: - One splint molded to limit PIP flex to 30degs and DIP flex to 20-25degs
- Other splint fabricated to hold PIPJ in FULL EXT during isolated DIP Flex limtd to 30-35degs
- End of 4wks–> pt achieves 70-80degs Active flex & Full EXT of PIPJ
- Composite MCP, PIP, DIP flex–> @ 4wks OR when exercise splints discontinued
- By 6-8wks–> LOW-int resisted ex’s, gradual use of hand for functional acts
Wrist- Extensor Tendon Repair
Delayed Mobilization Approach
- Ex’s delayed several wks after sx–> depends on ext tendon zone
- Resisted ex’s NOT initiated until 8-12wks
Achilles Tendon Repair
In terms of WB,
2 Approaches
- Conventional: 6wks IMMOB. and NWB
- EARLY Re-mob Approach: IMMED after sx OR after 1 or 2wks
Achilles Tendon Repair
Phase I: Up to 4-6wks
- AROM of NON-immob’d jts
- MM setting exercise of DFs, invertors/evertors and PFs–> @ 2wks
- Wt shifting in B/L stance while wearing orthosis AND when PWB permitted
Achilles Tendon Repair
Phase II: 4-6wks to 12wks
- Wean from orthosis
- Grade III mob tech’s
- Strengthening- OKC hip, knee, ankle; CKC like heel raise (B/L to U/L)
- Balance training wearing functional orthosis
- Gait and cardiopulm ex’s
Achilles Tendon Repair
Phase III: After 12-16wks
- Return to Pre-injury lvl
- Strength + MM endurance
- Plyos and TM walking on incline; advance training
