VANDERBILT MEDICAL CENTER

DEPARTMENT OF PHYSICAL THERAPY

  KNEE ARTHROPLASTY REHABILITATION

Purpose:

To guide patients through the pre-operative, acute and sub-acute phases of rehabilitation associated with Knee Arthroplasty, in an effort to assist the patient in becoming functionally independent following surgery.

Indications:

Patients who are considering or who have undergone Knee Arthroplasty (Total or Unicompartmental).

Contraindications:

Any medical, surgical, or post-operative complication as stated by the attending physician.

Physical Therapy Goals:

Pre-Operatively:

Early motion with progression as rapidly as possible toward full anatomical range of motion, limited only by the prosthetic design and the patient’s potential.

• Muscles strengthening.  Primarily of the hamstrings and quadriceps on the operative extremity.  An attempt should be made prior to obtain full active knee extension (i.e. no extensor lag).
• Prevention of knee flexion contracture.  Commercially available knee immobilizers are used by some surgeons in the acute rehabilitation phase for this purpose.  Towel rolls under the operative ankle may also be used to achieve full extension.
• Gait training.  Assistive devices are used to assist with balance, and facilitate normal gait pattern.

Sub Acute (Post-Discharge):

 

• Achieve maximal knee range of motion as allowed by the prosthetic design and limited only the patient’s potential.  Average knee motion, which may be achieved, is approximately 0-120° flexion.
• Muscle strengthening of both the quadriceps and hamstrings on the operative extremity.  Attention should also be directed toward any weakness present in the lower quadrant of the operative extremity as well as any generalized weakness in the upper extremities, trunk, or contra lateral lower extremity.
• Proprioceptive training to improve body/spatial awareness of the operative extremity in functional activities.
• Endurance training to increase cardiovascular fitness.
• Functional training to promote independence in Activities of Daily Living and mobility.
• Gait training.  Assistive devices are discontinued 3 to 6 week’s post-operative, per surgeon’s order.  Attempts should be taken to achieve a safe, efficient gait pattern at that time.

Physical Therapy Rehabilitation Guidelines

Milestones for Patient Progression:

• Patient using knee immobilizers are required to wear their immobilizers 6-8 hours per day for 2-3 weeks following surgery.  This is best accomplished at night while sleeping.
• Discharge from the Acute Care setting when the patient achieves 90° knee flexion, approximately 3 days post-operative.
• Discharge from Sub-Acute Physical Therapy Program to independent home exercise program with knee flexion to 110°.
• Patient are allowed to resume driving as outlined below:

1.      Operative left lower extremity-6 weeks post-operative.

2.      Operative right lover extremity-10 weeks post-operative.

Restrictions:

• Avoid prolonged kneeling positions.
• No running or involvement in sporting activities requiring high speed running and/or jumping.

Treatment Parameters:

Pre-Operative

• Participation in education class on Knee Arthroplasty.  Material covered in this class included discussion of Norman vs. abnormal knee joint anatomy, components of knee prosthesis, intra-operative sequence of events, identification of post-operative complications and preventative measures, admission procedures for Vanderbilt University Medical Center, post-operative rehabilitation, and discharge needs.
• Pre-operative Physical Therapy assessment at the time of the knee class.  This session includes a baseline assessment of joint range of motion, muscle strength, and mobility.

Acute Care (Vanderbilt University Medical Center)

Treatment protocol instituted day of surgery with efforts to achieve discharge report 3 days after surgery.

Day of surgery:

• Dr. Shinar:  Operative knee is placed in Continuous Passive Motion Unit at the completion of surgery in the operating room.  Hyperflexion range of motion setting of 60 to 100° is initiated.  Patients arrive on the Orthopedic Unit in the CPM and sleep the entire night in the unit at 100° of knee flexion at slow speed setting.
• Begin lower extremity isometric exercises and ankle pumps.  Encourage the patient to perform these exercises every 2 hours while awake.
• Begin assisted bed-to-chair transfer, weight bearing as tolerated on the operative extremity using an assistive device.

Post-Operative Day 1:

• Continue lower extremity isometrics and ankle pumps.

• Initiate upper extremity and contralateral limb strengthening exercises.
• Dr’s Limbird and Sciadin:  Operative knee is places in CPM Unit with range of motion and speed settings to the patient’s tolerance (see note below).
• Begin assisted ambulation on level surface using an assistive device, WBAT on the operative extremity.
• Begin discharge planning and home needs assessment.

*Note:  For these patients, the CPM unit is used during daylight hours only.  Nursing staff will remove patient from unit in the evening and place the operative extremity in the knee immobilizer.  If the patient has undergone bilateral TKA’s, the CPM is alternated from lower extremities every 2 hours.  Dr Shinar:  At 6:00 a.m., nursing increases CPM motion settings to 0-100 degrees of knee flexion, slow speed setting.  The CPM unit is used at the majority of post-op day #1, removed for out of bed activities and therapy sessions.

Post –Operative Day 2:

• Continue isometrics and begin assisted straight leg raises (SLR).
• Begin toe touching exercises (i.e., long sitting hamstring stretch.
• Begin active, active assisted flexion/extension exercises with the patient in a seated position on a firm surface (i.e. exercise mat).  Soft tissue massage/mobilization, gentle joint mobilizations, contract/relax exercises, etc. assist with increasing knee range of motion.  Ice/cold therapy should be applied to the knee at the conclusion of the exercise session.
• Continue assisted ambulation on level surfaces.
• Continue CPM usage PRN.

 

Sub-Acute Care

Patients who have acutely undergone Total Knee Arthroplasty are strongly encouraged to receive follow-up physical therapy in an outpatient clinic setting.  However, due to transportation limitations, support services, and/or functional limitations, this may not be a feasible option.  If this is the case, the multidisciplinary team will, prior to discharge from the acute care setting, will make arrangements for the patient to receive physical therapy services at home, Extended Care Facility (ECF), Sub-Acute Care Unit or Rehab Center.  Criteria for each setting are listed below:

 

• Home Health Physical Therapy-Patients with transportation difficulties, functional limitation restricting mobility (difficulty with transfers, etc).  Home physical therapy services are to be discontinued as early as possible and utilized no longer than 2 weeks-post surgery with services transferred to an outpatient setting unless approved by surgeon.
• Extended Care Facility Physical Therapy-Patients who live alone or have limited support services to assist with home care activities (i.e. no family members or friends able to help with homemaker activities and transportation to/from therapy) and whose overall endurance level is diminished and would interfere with their participation in a comprehensive rehabilitation program.
• Impatient Rehabilitation Center-Patients who pre-operatively lived alone and were independently functional in that environment and will be returning to that living arrangement at the conclusion of their rehabilitation; also, their general medical status and cardiovascular endurance is sufficient to participate in an intensive rehabilitation program.
• Dayani Center-Younger and physically active patients who have achieved functional range of motion and muscle strength in their operative knee maybe referred to the Dayani Center for instruction and/or supervision in general conditioning programs; this may be one the later phases of rehabilitation following TKA, involving a limited number of patients.

 

Within each of the setting, a comprehensive treatment program should be implemented based upon each individual patient’s needs and within established therapy restrictions.  Suggested physical therapy treatment/activities are listed below:

Modalities for Pain Control, Edema Reduction:

• Moist Heat
• FES
• TENS
• Ice
• Interferential
• Fluid-O-Therapy
• Galvanic Stimulation
• Negative Electrical Stimulation

Therapeutic Exercise:

• Passive, active-assisted, active lower extremity range of motion
• Contract/Relax exercises
• Isokinetics for passive knee range of motion
• Joint Mobilization (uni-directional) to the knee
• Soft tissue mobilization of the hamstrings and quadriceps
• Closed kinetic chain activities
• Stationary biking-no resistance to motion
• PNF (lower extremity patterns ) with/without resistance
• Lower extremity strengthening exercises using theraband
• Nordic Track
• Stair-Step Machine
• Aquatic Therapy/Activities
• Scar Massage/Mobilization-may be initiated after suture removal and when the incision is clean and dry

Gait Training:

Level Surfaces

• Forward Walking
• Sidestepping
• Backward or Retro-Walking

Uneven Surfaces

Functional Training:

• Standing Activities
• Transfer Activities
• Lifting
• Carrying
• Pushing or Pulling
• Squatting or Crouching
• Return-to-Work Tasks
• Sport Tasks

Endurance Training:

• UBE
• Upper and/or lower extremity restorator
• Ambulation activities
• One-leg cycling, using non-operative leg with resistance to motion.
• Aquatic Therapy

Balance/Proprioception Training:

• Tandem Walking
• Lateral Stepping over/around objects
• Obstacle Course
• Lower Extremity PNF Patterns
• Weight-Shifting Activities
• Closed Kinetic Chain Activities

 

VANDERBILT UNIVERSITY MEDICAL CENTER

REHABILITATION SERVICES

PHYSICAL THERAPY

Home Instructions Following Total Knee Arthroplasty

1. Never pivot or twist on your operative leg when turning.  Instead, take small steps to turn.
2. Walk in short sessions to gradually improve your physical endurance.  Progress distance and duration as your strength and endurance increase.
3. Continue to use your walker or crutches until your surgeon specifies otherwise. 
4. Stairs:

UP:  Step up with your non-operative leg first, and then raise your operative leg up to the same step.

DOWN:  Step down with your operative leg first, then lower your non-operative leg to the same step.

5. If wearing a knee immobilizer, continue to wear your immobilizer at night until your surgeon discontinues its use.
6. Do not sit for longer than thirty (30) minutes in any one position.  You need to stretch your knee muscles by exercising, standing, walking, or changing positions of knee.
7. Do not put a pillow under your knee when in bed.

_____________________________________, PT

Physical Therapy Telephone Number:

Vanderbilt Orthopedics (MCN 5/6) (615) 322-8900