PS201 Week 9 Notes - Facilitating Movement, Rehab Following Arthroplasty, & Total Knee Arthroplasty

Introduction to Stretching Techniques

  • Overview

    • Introduction to promoting movement

    • Increasing movement, especially for individuals with central nervous system damage (e.g., stroke)

    • Focus on stretching techniques and their importance

    • Importance for both personal practice and research

    • This is the first of four lectures

Lecture Structure

  • Upcoming Topics

    • Upcoming lectures on shoulder, hip, and knee joint replacements

Key Approaches to Movement Facilitation

  • Various techniques to enhance movement patterns in patients

    • Proprioceptive Neuromuscular Facilitation (PNF)

    • Bobath Concept

    • Neurodynamic Theory (NDT)

    • Motor Learning Principles

    • Biomechanics

Focus of This Lecture

  • Main focus on Proprioceptive Neuromuscular Facilitation (PNF)

  • Basic guiding principles for effective movement facilitation

Fundamental Principles of Manual Contact

  • Importance of hand placement in facilitating movement

    • Skin contact overlying muscles increases awareness and activity of those muscles

  • Manual contact usage

    • Pressure on skin assists with muscle movement and sensory cues for direction

    • Affects muscles and tendons involved in movement

    • Types of contact and hand placement

    • Proper hand positioning is crucial for effective facilitation

    • Harmful hand placement should be avoided (e.g., not blocking movement)

Guidelines for Effective Hand Placement

  • Key considerations

    • Be specific in hand placement to facilitate targeted movement

    • Maintain a balance in the amount of contact to avoid confusion

    • Keep at least one hand in contact with the patient for reassurance during movement

Movement Facilitation Techniques

  • Dynamic Stance and Ergonomics

    • Positioning oneself to utilize body weight effectively

    • Feet should align with direction of movement to optimize biomechanics

    • Avoid unnecessary arm strain by using body weight to assist in movement

  • Ugly mistakes to avoid

    • Do not block patient movement

  • Use of verbal commands

    • Keep instructions simple and clear to promote understanding

    • Research supports the use of external cues over internal cues for better patient outcomes

The Role of Vision

  • Visual feedback to aid learning new movements

    • Effective use of visual cues (e.g., mirrors, videos) to enhance understanding

    • Importance of physiotherapist being able to perform prescribed movements

Stretching Techniques Overview

  • Active vs Passive stretching

    • Distinction between active stretching (using antagonist muscles) vs passive stretching (using external assistance)

    • Active stretching examples provided

  • Objectives of Stretching Techniques

    • Overview and importance of stretches for increasing range of motion and flexibility

    • Insight on neurophysiological and tissue mechanics regarding flexibility

Overview of Active Stretching Techniques

  • Classification of active stretching methods

    • Static stretching: Holding a stretch at a fixed position

    • Dynamic stretching: Movement that involves lengthening and shortening muscles

    • Ballistic stretching: Rapid bouncing movements to increase range

    • Loaded stretching: Using weight to enhance stretch gains

Proprioceptive Neuromuscular Facilitation (PNF) Techniques

  • Overview of PNF styles

    • Hold Relax

    • Involves contracting the muscle that needs stretching

    • Facilitates relaxation of the muscle via autogenic inhibition

    • Reciprocal Relaxation

    • Involves contracting the antagonist muscle to facilitate the relaxation of the tight muscle

    • Rhythmic Stabilization

    • Combines both hold relax and reciprocal strategies for effective stretching without extreme effort

Theoretical Basis for PNF Techniques

  • Discussion on muscle tension and stretching

    • Active vs passive components of muscle tone

    • Active components: Central nervous system influences on muscle contraction

    • Passive components: Connective tissue structure's response to stretching

  • Mechanisms of Effectiveness

    • Muscle Spindles: Sense muscle length and changes, protect against overstretching

    • Golgi Tendon Organs: Monitor tension and help inhibit overly tight muscles

    • Autogenic Inhibition: Relaxation post-contraction of the target muscle

    • Reciprocal Inhibition: Contraction of antagonist for relaxation of the agonist muscle

  • Discussion of other factors such as Renshaw cells and supraspinal controls affecting flexibility

Stretch Tolerance and Passive Tension Relaxation

  • Definitions of stress relaxation and creep in connective tissues

    • Explain viscoelastic properties and their importance for understanding of muscle stretching

  • Stretch tolerance theories challenging traditional ideas on flexibility and pain limits

Application of Stretching Techniques in Clinical Settings

  • Application of PNF for improving range of motion, aiding recovery post-surgery (e.g., total knee replacement)

    • Discussion on using hold relax and reciprocal relax to improve knee flexion

    • Verbal cues given for effective communication during the stretching process

Evidence and Guidelines for Stretching Protocol Usage

  • Summary of research findings relevant to stretching efficacy

    • Importance of dosage timing for contracts during activities

    • Studies suggest effective ranges for contraction times and frequency

    • Relate findings to patient context and flexibility goals

Conclusions and Considerations

  • Final insights on flexibility training, the importance of variety in techniques, clinician adaptability, and patient compliance

    • Encouragement to integrate a combination of various stretching techniques for effectiveness and patient comfort

LECTURE 2: Rehab Following Arthroplasty

Introduction to Arthroplasty

  • Definition: Arthroplasty refers to joint replacement surgery, involving the surgical replacement of a joint with artificially produced materials.

  • Etymology: The term "arthro" means joint, while "plasty" involves shaping or forming, essentially indicating joint reconstruction.

Overview of Lecture Series

  • Upcoming Lectures: Focus will be on arthroplasty for the knee, shoulder, and hip across lectures two, three, and four.

  • Objectives:

    • Review surgical approaches for arthroplasty of the shoulder, knee, and hip.

    • Discuss the role of physiotherapy in patient assessment for joint replacement.

    • Cover rehabilitation strategies to maximize recovery outcomes post-surgery.

Types of Arthroplasty

  • Broad Categories: Joint replacements can be divided into two main types:

    • Total Arthroplasty:

    • Definition: A total joint replacement that involves replacing all joint surfaces.

    • Example: In a total hip replacement, both the femoral head and acetabulum are replaced.

    • Partial Arthroplasty:

    • Definition: Involves replacing only one surface of a joint.

    • Example: In a partial hip replacement, only the femoral head is replaced.

Reasons for Joint Replacement

  • Primary Indicator: Osteoarthritis, either localized or systematic, remains the most common reason for joint replacements.

  • Fractures: Serious fractures, particularly those that result in malalignment or incomplete healing, increase the likelihood of future arthroplasty.

  • Rheumatic Diseases: Patients with conditions like rheumatoid arthritis often require replacements, though physiotherapists typically refer to rheumatologists.

  • Bone Cancer: Metastatic cancer affecting bone integrity can necessitate joint replacement due to compromised joint surfaces.

Patient Characteristics in Joint Replacement

  • Demographics: The average age of patients seeking joint replacement is decreasing due to various lifestyle factors.

  • Sedentary Lifestyle: Increased sedentary behavior promotes lifestyle-related conditions, like obesity, impacting joint health.

  • Desire for Activity: Many individuals, particularly athletes and active people, may pursue replacement earlier to return to their desired lifestyle. Example: Andy Murray's hip replacement due to sports performance needs.

  • Socioeconomic Factors: Financial stability and knowledge influence the decision to opt for joint replacement, especially in financially guided healthcare systems like the USA.

Trends in Medical and Surgical Management

  • Evolving Techniques: Advancements in minimally invasive surgical techniques reduce trauma and recovery time compared to past decades.

  • Implant Longevity: Improvements in materials (e.g., titanium) have extended the lifespan of implants, e.g., up from ten years to potentially fifteen years.

  • Discharge and Rehabilitation: Trends are moving towards earlier discharge post-surgery, with at-home rehabilitation shown to enhance patient outcomes.

  • Prehabilitation:

    • Definition: A process to prepare a patient physically and mentally for surgery, raising their baseline functional capacity before the procedure.

    • Application: Common in joint arthroplasty, breast cancer surgery, and spinal surgery, involving a multidisciplinary approach including physiotherapists, nurses, occupational therapists, social workers, etc.

Importance of Prehabilitation

  • Education: Patients must understand the importance of prehabilitation to comply with exercise and lifestyle modifications to ensure better post-surgical success.

  • Functional Capacity: Prehabilitation leads to a higher level of functional capacity going into surgery, thus mitigating trauma stress from the surgery itself.

  • Patient Compliance: Ensuring understanding of rehabilitation importance directly influences compliance; educated patients are more likely to engage in recovery activities.

Physio Approach in Acute Phase Following Surgery

  • Immediate Goals:

    • Encourage patients to get out of bed post-surgery, essential for recovery despite potential discomfort.

    • Pain management: Addressing pain effectively is crucial for improving mobility rather than prolonging hospital stays.

    • Support Positioning: Proper positioning aids healing and helps manage swelling and restores range of motion quickly.

Subacute Phase Rehabilitation

  • Goals:

    • Introduce strength and endurance training.

    • Optimize neuromuscular control to facilitate normal movement patterns.

    • Gradual return to pre-surgery functional activity levels.

Advanced Phase Goals

  • Aim: Restore as much of the range of motion and functionality as possible, ideally pain-free.

  • Focus on:

    • Strength and Power: Emphasizing rapid force production to reduce fall risk, integrating strength training with power exercises in rehabilitation.

    • Functional Activities: Encourage and facilitate returning to advanced physical activities as part of rehabilitation plans.

Multidisciplinary Team Dynamics

  • Patient-Centered Care: The patient's needs and perspectives should guide rehabilitation goals, not solely the healthcare provider's objectives.

  • Team Communication: Continuous dialogue among surgeons, physiotherapists, nurses, occupational therapists ensures cohesive treatment plans.

  • Awareness of Surgical Outcomes: Not all surgical outcomes are positive. Physiotherapists should monitor for complications and be prepared to refer patients back to surgeons when issues arise.

Common Surgical Complications to Monitor

  • Risks include infections, deep vein thrombosis (DVT), wound complications, and joint dislocations.

  • Awareness is key to addressing possible complications or changes in patient status effectively.

Conclusion

  • Focus for Future Lectures: Detailed examination of knee, shoulder, and hip replacement processes will ensue, with emphasis on surgical techniques, recovery protocols, and physiotherapy roles.

LECTURE 3: Total Knee Arthroplasty

Introduction to Knee Joint Replacements

  • Welcome and Overview

    • First lecture on types of joint replacements focusing on the knee.

    • Objectives of the lecture:

    • Review influence of surgical approach and implant type on outcomes.

    • Discuss physiotherapy role in Total Knee Replacement (TKR) rehabilitation.

    • Explore common complications post-TKR.

Increasing Incidence of Knee Replacements

  • Statistical Trends

    • Total knee arthroplasty (TKA) projected incidence to rise by 20% by the year 2030.

    • Factors contributing to this trend:

    • Increasing sedentary lifestyle.

    • Longer life expectancy.

    • Lower threshold for recommending knee replacement surgery.

  • Demographics

    • Females have a higher incidence of knee replacements than males.

    • Average age for recipients is decreasing:

    • The percentage of patients over 70 years old declined from 53.4% (2003) to 44.5% (2013).

  • Societal Costs of Knee Replacements

    • Overall health costs in Australia: AUD 9.5 billion.

    • Projected healthcare costs by 2030 increased to AUD 5.2 billion.

    • Additional costs include lost workdays, long hospital stays, and rehabilitation needs.

Indications for Total Knee Replacement

  • Criteria for Recommending TKR

    • Pain: Significant pain impacts quality of life.

    • Function: Difficulty performing activities of daily living (ADLs).

    • Radiological changes in knee imaging: Can lead to misinterpretation and not always correlate with pain severity.

    • Failure of conservative treatments: Often questionable if proper rehabilitation was followed.

  • Indications for TKR

    • Symptomatic osteoarthritis or inflammatory arthritis not responding to conservative therapy.

    • Severe knee pain or stiffness limiting daily activities.

    • Moderate to severe knee pain at rest, day or night.

    • Chronic inflammation and swelling of the knee not relieved by rest/medication.

    • Knee deformity affecting function, though structural alignment doesn’t always impact functionality.

  • Kellgren Lawrence Scale (KL)

    • A four-point scale grading joint space narrowing and severity:

    • Grade 3 defined as multiple osteophytes and narrowing of joint space.

Role of Physiotherapy in Preoperative Rehabilitation

  • Benefits of Prehabilitation

    • Preoperative exercises shown to improve outcomes by enhancing quadriceps strength, walking speed, and general mental health.

    • Studies indicating prehabilitation effectiveness:

    • Improved performance in functional tasks and decreased pain measures.

  • Challenges in Evidencing Prehabilitation

    • Conflicting results in literature regarding its lasting benefits.

    • Calls for physiotherapists to enhance exercise prescription skills and individualized care in rehabilitation.

Surgical Approaches to Total Knee Arthroplasty

  • Traditional vs Minimally Invasive Approach

    • Traditional approach involves midline incision of 20 cm, minimising sight through the surgical field.

    • Minimally invasive technique uses 10 cm incision, sparing quadriceps muscle, leading to:

    • Less pain and bleeding.

    • Early mobilization and quicker recovery.

    • Importance of surgical experience in minimising complications such as implant malposition.

  • Implications of Surgical Approaches

    • No significant clinical difference in muscle sparing outcomes reported in studies.

    • Highlights the importance of outcomes beyond aesthetics, such as functional recovery and pain management.

Types of Implants in Total Knee Arthroplasty

  • Fixed vs Mobile Bearing Implants

    • Fixed Bearing

    • Stays fixed, allowing no rotation, promoting lower contact stress but high torque risk leading to prosthetic loosening.

    • Mobile Bearing

    • Allows some rotation increasing movement options and minimizing fatigue fractures.

    • More costly, but no significant clinical outcome differences found between fixed and mobile designs in studies.

  • Bicruciate Retaining vs Unicompartamental Implants

    • Bicruciate retaining models mimic the anterior and posterior ligaments.

    • Unicompartmental implants replace one side (lateral or medial).

Physiotherapy Role Post Total Knee Replacement

  • Immediate Post-operative Rehabilitation Goals

    • Set clear patient goals promptly.

    • Manage pain and promote early mobility.

    • Restore range of motion and reduce swelling.

    • Increase strength and functional capabilities for ADLs.

  • Evaluating Patient Progress

    • Use various outcome measures in clinical settings for assessment:

    • Patient-reported outcome measures (PROMs) like the Knee Society Clinical Rating System.

    • Objective measurements include timed up and go tests, walking tests, and single leg stance tests.

Rehabilitation Strategies and Techniques

  • Methods for Effective Rehabilitation

    • Early rehabilitation and telehealth methods show promise.

    • High intensity and high velocity exercises can facilitate faster recovery.

    • Common adjuncts to rehabilitation:

    • Continuous Passive Motion (CPM) machines: Limited evidence supporting routine use.

    • Hydotherapy: Can be beneficial in reducing loading on joints during early stages.

    • Neuromuscular Electrical Stimulation (NMES) targets quadriceps strength and offsets disuse.

    • Balance training and functional rehabilitation incorporating agility drills.

  • Pain Management

    • Manage postoperative pain to facilitate mobility and rehabilitation success.

Complications and Patient Outcomes

  • Common Post-operative Complications

    • List of complications that can impair rehabilitation includes:

    • Quadriceps weakness due to pain inhibition.

    • Knee flexion contracture affecting overall activity and quality of life.

    • Peripheral nerve issues, although rare.

    • Leftover discrepancies in leg length affecting mobility.

  • Patient Specific Factors

    • Elderly patients tend to struggle with rehabilitation due to comorbidities and depression.

    • Physical jobs may affect return to work statistically.

    • Return to sport varies widely, with fewer successful returns to high-impact sports.

Final Remarks and References

  • Conclusions

    • Importance of mobilising patients early and setting functional goals.

    • Individualisation of physiotherapy treatment is crucial.

    • Need for constant communication with surgical teams to optimize recovery.

  • References

    • Comprehensive list of studies and articles cited in the lecture for further reading.