Hello Everyone,
This week the importance of physiotherapy rehabilitation post knee, hip, and shoulder replacement was highlighted. This week I had a new patient who had bilateral total knee replacements in 2001 and 2002. She reports not having had physiotherapy at any stage post surgery. She presented to the clinic with an abnormal gait pattern using a walking stick for assistance. After having a closer look at her gait I noticed it was actually a bilateral compensated Trendelenberg gait pattern. The reason this lady presented to the clinic was due to bilateral leg weakness and increased incidence of falls. After my assessment I discovered she had 72 degrees of knee flexion in her left knee and 80 degrees of flexion in her right knee. Post knee replacement we would want at least 100 degrees of flexion for most functional tasks. MMT showed she has grade 2; hamstrings glut med, glut max, grade 3 quads and grade 4 gastrocs. As you can see her major problem is weakness in her lower limbs which is also affecting her ROM at her knee as well. This was the first time I have seen an example of such massive de-conditioning. It surprised me that a 63 year old lady who use to square dance for 25 years prior to knee replacement could have ended up with grade 2 muscle strength. I was surprised to see this type of weakness in the outpatient clinic I would have expected this on a neurological ward but not with someone walking into the outpatient clinic. It was a good learning lesson for me and will be a great challenge to strengthen this lady. It’s a shame it is my last week I would have enjoyed being able to monitor her progression through an extensive strengthening program. Being able to use the skills we were taught for muscle strengthening use of eccentric and concentric, gravity eliminated positions as well as isometric resistance to aid this ladies rehabilitation. I would have learned a lot with regards to time frame for muscle strengthening as I don't feel confident with estimating these times. It would have been very rewarding to see her walk with out her current pattern. My question is how long do you think it would take for her to regain a normal gait pattern or do you even think this is possible with her present de-conditioning?
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2 comments:
Hey Dani,
That’s a really good question and there are a number of considerations that need to be factored in when trying to determine if this patient will achieve a 'normal gait pattern'. Since the TKR's were performed 6-7 years ago there seems to be a lack of education/understanding on the patient’s behalf regarding exercise and maybe some underlying fear of mov’t due to her falls.
Compliance to a HEP will need to be determined and a relatively aggressive treatment approach (strengthening, balancing, education) should be undertaken or I suspect that improvement will not be seen. As the patient has had a number of falls safety will be a major factor in prescribing exercise as she will not comply if she feels unsafe or be at risk of a fall.
I think global/Fx conditioning exercises will be more important and understandable from a pt’s view point than single muscle exercises. As there are so many muscles that are weak and they will probably lack the understanding behind this. Having said this though that can be quite challenging choosing appropriate ones as safety is vital for this patient.
In terms of how quickly you could expect muscle strength to improve you would expect to see some initial gains quickly due to her commencing an exercise program. How far she progress will come down to frequency, duration, mode and prob. most importantly motivation.
It wouldn’t be unreasonable to expect this patient to achieve grade 4-5 strength for all the muscle groups in 4-6/52. However this may not translate to a normal gait as balance issues will also need to be addressed.
It is a shame you won’t get longer with her but hopefully she can come back and see the next pt
Good thoughts, Royal.
From me Ma's experience, i would say that it depends alot on the PT who is overseeing the rehab.: it is not only a matter of the 5-6 week time frame needed to get improvements in muscle strength (and I guess longer if the weakness is that severe) and whatever time is needed for ROM, but also how well the pt manages to get these changes into gait.
On my musculo prac, I have seen more than one pt who is now strong & flexible enough to walk properly but does not due to the ingrained nature of the compensations...
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