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Screening complicated patients waiting for a total knee arthroplasty may provide insight into worsening condition? Kelly Danks PT,DPT Geriatric Resident
Patient History • The patient was a 49 year old male with a 4-5 year history of osteoarthritis (OA) aggravated by a fall at work 2 months prior to physical therapy referral. • He had 2 L knee arthroscopic surgeries 23 years ago due to infection. Otherwise his past medical history is unremarkable.
What subjective information should be obtained from this patient? Why?
Subjective Information • Mechanism of injury: He stepped into a hole and twisted his L knee prior to falling. • A recent cortisone injection reduced his pain to a 4/10 overall. He describes his pain as “diffuse”. • Functionally, he has difficulty performing heavy lifting/manual labor required of his job as a researcher in the UD Department of Agriculture, playing with his children, walking, prolonged standing, and descending stairs. • Other complaints: intermittent buckling and instability
What other information can you ask that will help you with the differential diagnosis of this patient?
Question # 1 • Which type of imaging is the best evaluation of the ACL? • MRI • Dexa scan • CT scan • PET scan
Imaging • X-ray: significant L medial knee OA • MRI: meniscal tear and partial ACL tear
Objective Data • Gait observation: L antalgic gait, decreased L LE stance time, increased L LE extension throughout gait cycle, lateral trunk sway, L LE varus. Pt without an assistive device. • Patellar Mobility: hypomobile all directions • AROM/PROM: 0°-107°/112° • Knee Outcome Survey: 48% • Global Rating Score: 50% • Special Tests • Lachman’s/Anterior Drawer/ Pivot Shift: all inconclusive secondary to guarding • Step test: Unable to complete secondary to pain and instability with SLS • KT Testing: R= 6 mm L= 9 mm
What are the patient problems? Think ICF Disablement Model
Disablement Model: ICF • Health Condition • Significant medial knee OA • Partial ACL tear • Meniscal tear • Impairments • Pain • Functional quadriceps weakness • Poor quadriceps activation • Decreased patellar mobility • Swelling • Gait dysfunction • Decreased stability • Functional Limitations: Activity/Participation • Inability to lift heavy objects required of full duty status of his job • Inability to run so that he can play sports with his kids • Difficulty with negotiating stairs descending>ascending, limits # of usages
Established Goals • STG (4 weeks): • Increase L knee flexion ROM by 5˚ or more • Decrease swelling by 1 cm or more at mid patella • Increase patellar mobility by 50% or more of the uninvolved side • LTG (8 weeks): • Increase KOS score to 80% or more • Increase QI without stim to 85% or better • Pt will work a full day with 2/10 or less L knee pain *PROGNOSIS*
Plan of Care • Twelve sessions (1 month) of physical therapy included: • ROM activities (Ex: bike) • Stretching (Ex: hamstring/prone quad stretch) • Joint Mobility • Patellar mobilizations • Functional Activities • Gait training • Quadriceps Neuromuscular Training • Isokinetics on KinCom • Perturbation training • With and without FES (Ex: sit<>stand with FES, SAQ, TKE with/without FES) • NMES • Pain • Modalities for pain (Ex: ice) • The patient also received a GII medial unloading brace.
Question #2 • The patient was dispensed a GII medial unloading brace mainly because • he has a partial ACL tear • he has a varus knee with medial compartmental OA • he has a meniscal tear • he has quadriceps weakness
Subjective Reports • “I still get pain during my work day. I have to have other people do the heavy lifting.” • “Wearing the unloading brace decreases my pain during walking, so I can walk longer distances at one shot.” • “The surgeon told me I have no cartilage left, I am bone on bone.” • “My knee is same old, same old.”
POLL • What do you think, the patient is…. • Getting better • Staying the same • Getting Worse
**Burst was re-checked** Treatment Interventions Response 0˚-105˚; a 7˚ loss in flexion. No change 0/10 at rest, 7/10 walking without brace (4/10 prior); feels better/walks longer with brace (did not rate pain on VAS) No change Able to tolerate Versa-Stim Difficulty with equal weight bearing and maintaining minimally flexed knee. Unable to perform a L SLS unless knee is locked out. No change KOS: 18% improvement GRS: 10% improvement 9. SLS: R: 31.99 seconds L: 8.69 seconds 6MWT: 1642 feet or 273 feet/min TUG: 7.72 seconds • AROM • Swelling • Pain • Patellar Mobility 5. NMES 6. Perturbation Training 7. Gait Training • Outcome Surveys • Functional Testing
Burst Test At Visit 12 (1 month) *Patient with painful L hamstring during test.
Question #3 • With his response to physical therapy thus far, what would you recommend… • Discharge physical therapy immediately as it has been an inappropriate intervention • Refer back to the physician with the recommendation of possible surgical consultation • Continue with the current POC, doubling his strengthening exercises • Don’t panic, reassess in 6 weeks, strengthening is a slow process
Question #4 • Theoretically, preoperative quadriceps strength is • Important because it may maximize postoperative recovery and be predictive of functional outcomes in patients with total knee arthroplasty • Important, the stronger the quad the less likely to have medical complications following surgery • Not important, he can get stronger later • Quad strength is no big deal, he is getting better, his KOS has increased
Surgical Intervention • Three months later the patient underwent a L total knee arthorplasty and returned to physical therapy 3 weeks after surgical intervention.
Post-Operative Progress • After 8 weeks of skilled outpatient PT per U of D TKA guidelines • Lacking 1˚-90˚ • 4 weeks after the manipulation (12 weeks s/p TKA) • AROM 0˚-113˚ • KOS: 91% • GRS: 90% • Back to work full duty • Going to the gym • 0/10 pain • No functional limitations
Question #5 • It was important to get the patient in for a manipulation as soon as possible because • he shouldn’t have been manipulated, lacking 1°-90° of knee ROM is functional • manipulation is highly effective at any stage of TKA recovery • studies show that manipulation is most effective in patients manipulated within 8 weeks • Stimthe quads, I thought we only manipulate backs?
Preoperative Quadriceps Strength Predictive of Postoperative Outcomes • Functional limitations: • Inability to perform heavy lifting that is required of his job • Walking • Prolonged Standing • Inability to run and play with his children • Descending stairs • KOS: 48% • GRS: 50% Uninvolved Quadriceps Strength: 1006 N; 100% CAR Preoperative Strength Uninvolved Quadriceps Strength: 905 N; 100% CAR Postoperative Strength 12 wks post op 851 N 100% CAR 781 N 76% CAR Initial PT Evaluation • Functional limitations: • Difficulty kneeling and squatting only • KOS: 91% • GRS: 90% 683 N 90% CAR 1 Month T K A 585 N 82% CAR 1 Week Later Falls Risk