Fundamental Treatment of a Knee

Replacement

Swelling control and Range of Motion are 2 of the most important components of

rehabilitating a Total Knee Replacement

Knee ROM is very important and is best to start ASAP after surgery

Patients are racing against the clock with scar tissue production after surgery

There is a rapidly closing window of

opportunity to achieve ROM. The longer the patient waits, the more difficult it is to

achieve knee ROM

Knee Extension

Normalizes Gait Full knee extension is required for a normal gait

pattern.

Reciprocal Inhibition If the posterior capsule is tight it is difficult to

achieve full strengthening capabilities of the quadriceps. Investigators have linked the decline in walking speed

and stair climbing to persistent quadriceps deficit.(7)

Knee FlexionBelow are the knee flexion requirements for various

tasks to be performed properly. (1)

Climb Stairs 83 degrees Descending Stairs 100 degrees Sitting Down 93 degrees Tying shoes 106 degrees Lifting Grandchild 1 17 degrees Gardening 125 degrees

It is better to prevent swelling instead of trying to reduce it after it happens

Swelling will:

• Increase pain• Limit patient’s ability to flex and extend knee• Create muscle shutdown• Provide poor proprioception

This will alter their gait pattern, limit ROM, inhibit ability to perform exercises, and

may ultimately delay the patient’s recovery

Many professionals treat a TKA as a normal knee and completely disregard

that this is a big surgery.

A TKA surgery physiologically induces the complete healing process, beginning with inflammation.

We have found that respecting the early phase of healing (ie inflammation) will allow quicker return of knee motion and quad control and thus a much speedier recovery. An injured knee is treated with RICE to allow quicker return to activity

We feel the same respect should be given a knee just receiving a TKA

R.I.C.E. Rest: “limited activity” Instead of being up in a chair and

walking constantly, patients are up only for therapy sessions, bathroom breaks, and when doing exercises (the goal is to normalize gait. “Walking” 200 feet prior to d/c on a bent, non-functional knee only provides bad habits that have to be corrected later, at the cost of therapy sessions).

Ice: In our setting this is achieved with a water circulating ice machine.

Compression: In addition to a bulky dressing and TED hose, a small compression component is achieved when wrapping the pad from the ice machine around the knee.

Elevation: LRU pillow

LRU Pillow There is a new product available for patients

receiving total knee replacements: the LRU Pillow.

The LRU pillow is designed to elevate the leg while keeping the knee as straight as possible.

The LRU Pillow is an effective, light-weight, and user-friendly (for patient’s and caregivers) tool.

Many hospitals utilize the CPM machine for TKA patients during their hospital stay and 2 weeks beyond their hospital stay. 

We believed that there was a benefit to using the CPM machine.  However, our findings revealed elevation is the beneficial component and not necessarily the motion of the machine.

CPM Machine???

What Does the Literature Read?

a Cochrane Review from 1966 to 2009 reveals little benefit for the use of the CPM. (2) It is not detrimental; however, the machine:

Does not assist with full knee extension (the machine may read it is in full extension, but most patient’s knees are not straight while in the machine.)

Weighs 35 pounds. Many patient’s caregivers struggle to physically manage the machine.

Many patients and caregivers position the leg improperly in the machine which can ultimately do more harm than good.

Confines patients to the bed while using the machine.

Is not accommodating to patients who are large, short, or overweight.

We wanted an alternative device with beneficial features:

Elevation to achieve edema control Positioning to encourage knee extension

while resting Light-weight for patients and caregivers User-friendly Accommodate various patient sizes Allows for use in recliners, sofas, bed, etc. Capability of use during entire recovery

process

The LRU Pillow exhibits all of these features

We went through our Institutional Review Board and performed a prospective study comparing pain and knee ROM at post-op day 2, post-op day 16, and 2 months using either the CPM machine or the LRU pillow

The results indicate, as we expected, no significant difference in pain or knee ROM. (3)

Prospective Study

CPM flexion values

708090

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1 2 3 4 5 6 7 8 9 10

patient number

deg

rees f

lexio

nCPM d/c

CPM 2 wk

CPM 2mo

708090

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degrees flexion

1 2 3 4 5 6 7 8 9 1

patient number

LRU flexion values

LRU d/c

LRU 2 wk

LRU 2 mo

Retrospective Chart Review We then performed a retrospective chart

review of our TKA patients from January 2011 to September of 2011. We looked at knee ROM at hospital DC and surprisingly found a significant improvement in knee flexion with the use of the LRU pillow compared to the use of the CPM machine. (4)

LRU vs. CPM Range of Motion Outcomes

0-5 Degrees > 85 Degrees > 90 Degrees

CPM (n=111) 87% (97/111) 67% (74/111) 60% (67/111)

LRU (n=96) 95% (91/96) 84% (81/96) 78% (75/96)

What about using nothing?

We were also able to look at knee ROM outcomes with patients who used nothing to elevate the leg.

These patients actually yielded the worst results.

With this observation we knew that elevation was the component that we did not want to eliminate.

Does It Matter?

While it might be true that long term ROM outcomes are similar while using various early treatment interventions, the statistics show that other outcome measures are being left unaddressed.

We must not only measure pain and ROM in these patients, instead we also must focus on the functional outcome.

Studies have shown that the current measures of success following a total knee replacement (pain

and ROM) may not be enough to ensure a positive experience and a return to safe functional levels

24% fall within the first year (5) Total knee replacement patients walk 18%

slower (6,7) Total knee replacement patient climb steps

51% slower (6,7) Total knee patients typically have a 20-25%

quadriceps strength deficit prior to surgery, 4 months post-op they have a 40% deficit, and one year later they return to a 20 – 25% deficit(6,7,8)

Early ROM is Defined as ROM achieved in the 1st 2 weeks.

The goal of this accelerated ROM program is to have 0-120 degrees of motion early.

Once this early ROM is achieved, then outpatient therapy can focus on: Strength Proprioception Neuromuscular re-education Balance Gait quality

Outpatient therapy goals will define the final outcome for the total knee

population

If a patient arrives to outpatient therapy with an edematous knee and limited ROM, then more therapy sessions must focus on overcoming these deficits.

If patients begin their outpatient therapy visits with the ROM goal met, functional outcomes can then be the focus of the precious few visits that insurance companies are allowing.

Achieving knee ROM is just the tip of the iceberg in TKA

Rehabilitation If we do not achieve ROM that allows

function, therapy cannot and should not move further with higher level rehabilitation. (strength, proprioception, neuromuscular re-education, balance, gait quality)

Early intervention should focus on promoting ROM.

Controlling edema is critical in the early phases of rehab. Edema can have detrimental effects on knee ROM, especially flexion. Further, once swelling begins in a lower extremity, it is challenging to reverse and can linger for months, jeopardizing outcomes.

EDEMA CONTROL AND ROM

These two goals can be accomplished with the aid of the LRU Pillow... A high-density foam pillow that comfortably elevates the leg at a 20 degree angle to control edema. The ankle is secured with a wedge-shaped design to keep the leg in a neutral position, thereby, encouraging knee extension. The LRU Pillow is light-weight and portable. It can be utilized in various locations, such as, bed, recliner, couch, etc

The LRU Pillow was designed by an orthopedic surgeon and a physical therapist. The light-weight, portable, comfortable, and user-friendly characteristics of the LRU Pillow increase patient use during the critical stages of healing, resulting in the best possible outcomes and high patient satisfaction.

AAROM TKA at Hospital Discharge

September 2011Pt. ID hyperextension neutral flexion # PT Tx’s

1b 1 0 92 4

1l 0 0 97 4

2l 2 0 104 4

3l 0 0 96 2

1w 0 0 95 2

4l 0 0 87 2

1mw 1 0 106 3

1k 2 0 103 3

5l 0 2 100 4

6l 0 0 75 5

2w 0 0 90 2

7l 1 0 110 2

1jl 2 0 95 4

1s 0 0 90 3

2mw 3 0 100 2

8l 0 0 109 2

3w 0 0 100 2

1b 2 0 98 3

18 Patients

Full Knee Extension: 94%

Knee Flexion > 90 degrees: 89%

Average Knee flexion: 97 degrees

Average PT treatments: 3

All patients utilized the LRU Pillow during their hospital stay

OTHER USES The LRU Pillow was initially designed for the

rehabilitation of total knee arthroplasties.  We are finding similar success with other diagnoses:

Proximal Tibia Fractures Femur Fractures Patella Fractures ACL Reconstruction Foot/Ankle Surgeries Venous Disease Lower Extremity Burns

References 1. “Are You Boomer Ready: Total Joint Rehabiliation.”

A CEU course by John O’Halloran. 2. Harvey LA, Brosseau L, Herbert RD. Continuous

passive motion following total knee arthroplasty in people with arthritis. Cochrane Database of ystematic Reviews 2010,Issue 3. Art. No.: CD004260. DOI: 10.1002/14651858.CD004260.pub2

3. Delcamp J, Lawless M., Johnson S. Effects of the LRU pillow on active assistive knee range of motion and pain scores following a total knee replacement surgery .Unpublished. http://www.msmproductsllc.com/.

4. Johnson S. Effects of the LRU Pillow versus CPM machine on AAROM at Hospital Discharge following a Total Knee Arthroplasty. A Retrospective Chart Review. Unpublished. http://www.msmproductsllc.com/

References Cont. 5. Swinkles A, Newman JH, Allain TJ. A prospective

observational study of falling before and after knee replacement surgery. Age Ageing. 2009; 38:175-181.

6. Noble PC, Gordon MJ. Weiss JM, Reddix RN, Conditt MA, Mathis, KB. Does total knee replacement restore normal knee function? Clin Orthop Relat Res. 2005:157-165

7. Walsh M, Woodhouse LJ, Thomas SG, Finch E.  Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects. Phys Ther.1998; 78:248-258.

8. Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps strength and the time course of functional recovery after total knee arthroplasty.JOSPT.2005;35:424-436