I was doing Musculoskeletal Outpatients placement in December and was treating a 72 years old patient who had TKR 6/12 ago.
She was transferred to physiotherapy because she has lost full knee extension over time since the operation. On objective assessment, she showed -5 degrees extension of the operated knee, 10 degrees quads lag on both sides, poor gait pattern with dragging her feet and poor standing balance. So I did massage on the popliteal fossa to break down soft tissue contracture, taught her passive stretching in sitting, SQE so as to written HEPs given to her, gait re-education and balance exercises. When I saw her each week, I checked HEPs and reassessed knee ROM and VMO strength, though there was no improvement. I felt I didn’t achieve anything while I was seeing her 4 times during the placement and it was quite frustrating.
While I was focusing on the knee, I didn’t realise her history that she had a car accident years ago which caused her traumatic brain damage as well as her back problems. So even though she told me that she had done HEPs and showed a good compliance, I didn’t necessarily have to believe that and I was not sure whether the reason why she was not improving was because of her memory problem or the time that it takes for knee ROM and VMO strength to improve.
So from this experience I learned that I should look at the whole picture including other joints as well as cognitive aspect when I treat patients. In addition, 5 degrees loss of knee extension sounds subtle though it affects her activities significantly like weak VOM, her standing posture which might aggravate her existing back problem and cause the opposite knee flexed and also her unstable gait pattern. It is important to get the full knee extension and it is not easy to achieve as I thought especially for old patients.
It would be great if anyone has comments on ‘tricky’ HEP compliance and any good idea to improve her problems in this case.
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3 comments:
I remember from my ortho placement last year that in some cases patients post TKR never regain there full extension ROM, especially in the elderly. So while it maybe a goal of yours, it might never be achieved. Just wondering if you tried mobilisations in this pt (ie AP of the femur in long sitting/supine)? I know that you can get braces that would passively stretch the knee into extension and could be worn while the patient is resting at home (don't know if this would be practical for this patient?). Anyway just a few ideas!
Cheers
Nico
Hey,
I can totally understand how frustrating it can be implementing Rx’s and HEP and feeling as though you are getting no where. As you mentioned it is really important to look at the patient as a whole rather than just a TKR and consider why they are not improving (eg. poor compliance or lack of understanding). Other factors to take into account, as to why you may not be achieving full knee extension is the pre-operation status of the patient. If they have suffered from an OA knee for years then there may have been quite significant changes not only at the affected knee (muscle length/strength, proprioception) but associated changes as other areas of the body as you have mentioned.
In reflecting upon a similar situation I was in, I think we need to determine the factors that are leading to non compliance and work out strategies as to how HEP can become a daily part of life. So as to reinforce benefits gained at Rx. Weather it is through education of the patient to make sure they understand the implications of not achieving optimal recovery and how this affects their QOL. Or if it is due to memory loss then possibly getting a friend or family member to be present during Rx so they can assist with the patient implementing their HEP could be another option.
I think as we gather more experience with our clinics hopefully we can develop further strategies/tools to assist us with improving patient compliance and thus a better outcome for the patient and us as clinicians.
Good thoughts, Nico and 'Royals'.
One of the easiest ways to assess if a pt is complying with the HEP is to ask them to show you the X.s.
I reckon this is justifiable even if you think they are being compliant: it is important to see that they are getting full ROM, recruiting the right muscles, not doing trick moves, etc. And, if they can't show you the X.s, chances are they aren't doing them at least 3/week.
Cognitive impairments add a tricky extra dimension; but I figure the same rules apply: if the pt can't show you the X.s, then you may need to try to see that a family member / carer gets the gist of the X.s and helps the pt.
I think Nico is right that some pt.s never regain full AROM, but I think this should be reason for us to try even harder: I think that a lot of those cases involve situations where pt.s don't understand the importance of the rehab goal (e.g. getting full KE so that they can walk and so avoid disability) and /or don't understand how the X will get them there (e.g. including the fact that that they will have to do the X almost daily for weeks to get there).
Ed
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