Pilates for my Post-operative Total Knee. Replacement Patient. Rena Regan. June Course Year Chicago, IL

Transcription

1 Pilates for my Post-operative Total Knee Replacement Patient Rena Regan June 2018 Course Year 2015 Chicago, IL

2 Abstract A Total knee replacement surgery is considered for patients whose knee joints have been damaged by either progressive arthritis, trauma, or other rare destructive diseases of the joint. During a total knee replacement, the end of the femur bone is removed and replaced with a channeled plastic piece with a metal stem. Rehabilitation after a total knee replacement surgery is very important. If a patient does not receive rehabilitation after, they could end up with chronic knee pain and stiffness which will then lead to abnormal gait patterns, poor strength, flexibility, balance and coordination. Patients usually can begin their rehabilitation 48 hours after surgery. The surgeon s protocol that includes the phases of rehabilitation is very important to follow so that the patient will not fall behind during the rehabilitation process. In the early stages of rehab, Pilates on the reformer will assist in achieving normal and full range of motion with out gravity putting more pressure and strain on the knee joint. In the later stages of rehab, Pilates on all equipment can be beneficial to improve strength, balance and coordination. This paper will provide the phases of rehabilitation for a total knee replacement with use of BASI Pilates block system. 1

3 Table of Contents 1. Abstract 2. Table of Contents 3. Anatomy 4. Information on the components of the knee and Total Knee Replacements 5. Information on the components of the knee and Total Knee Replacements 6. Case Study 7. Rehabilitation program using the BASI Block System 13. Results 14. Conclusion and References 2

4 The knee is the largest and most complex joint in the body. The knee joins together the thigh bone, shin bone, fibula, and the patella. The knee is designed to fulfill a number of functions: 1. Support the body in an upright position without the need for muscles to work. 2. Helps to lower and raise the body. 3. Provides stability. 4. Acts as a shock absorber. 5. Allows twisting of the leg. 6. Makes walking more efficient. 7. Helps propel the body forward. 3

5 The main muscles that make up the knee joint are: Quadricep muscle group that is used to extend the knee, Hamstring muscle group that is used to flex the knee, and the gastrocnemius muscle that is also used to flex the knee. 4

6 A total knee replacement surgery is needed when people completely loose function of the knee and damage the knee to a severe degree. Which can be caused by chronic osteoarthritis, rheumatoid arthritis, severe knee injuries or an infection. During a knee joint replacement surgery, the damaged parts of the knee joint are removed and manufactured components (prothesis) are then placed on the knee. The prosthesis can have both metal and plastic parts. The surgery lasts about two hours. About 48 hours post-surgery physical therapy and rehabilitation will begin. 5

7 Case study For this case study, I used my knowledge and expertise as a licensed Physical Therapist Assistant and Pilates practitioner for one of my patients that underwent a total knee replacement surgery. Her name is Nancy G, 74 years old. She received her right total knee replacement on the 22 nd of January On February 10 th, 2017 she presented to our office and a full physical therapy evaluation was performed. Her Functional limitations were as follows: 1. Right knee abnormal active and passive range of motion: Right Knee flexion: 87 degrees with pain at the end of the range. Right Knee Extension: -7 degrees. Left knee Flexion: 125 degrees. Left knee extension: 0 degrees. 2. Circumference measures showed post-surgical swelling noted in the peri-patellar region as well as in the popliteal space of the knee. Measured at the midline: Right knee 23 inches, Left 14 inches. 3. Manual Muscle Test showed poor right knee strength and stability: Right Knee flexion 3-/5 and extension 3-/5 (Unable to tolerate any manual resistance against gravity). Left knee flexion 4+/5 and extension 4+/5 (Able to complete full range of motion with resistance against gravity). 4. A gait analysis showed she had poor gait patterns. She presented with an antalgic gait pattern which has decreased stride length, knee flexion, hip flexion and heel striking on the right. 5. Poor static and dynamic balance. Unable to perform a single leg stance on the right. After the evaluation was performed, a plan of care was made which included the treatment plans with the surgical protocol and patients goals. The surgical protocol is divided into weeks: Week 1: Decrease pain and inflammation. Increase passive and active range of motion to 90 degrees of knee flexion. Week 2-4: Continue to decrease pain and inflammation. Increase passive and active range of motion to at least -10 of extension and 100 degrees of flexion. Initiate functional exercises as tolerated (i.e quadriceps, VMO, hamstring, hip/gluteal muscle exercises and core stabilization exercises). Week 4-6: Continue to improve right knee range of motion to at least -5 degrees of extension and 110 degrees of flexion. Normalize gait patterns. Increase the intensity and or resistance of all functional exercises. Initiate standing dynamic and static balance activities. 6

8 Week 6-8: Patients should have improved gait patterns. Range of motion should be 0 degrees of knee extension and 115 degrees of knee flexion or more. Initiate single legged exercises as tolerated. Week 8-12: Range of motion should be at a normal functional range of motion and equal with the other knee. Discharged with a home exercise program and or weaned into gym program. The patients short term and long term goals: 1. Be able to walk without pain. 2. Be able to ascend/descend the stairs without pain. 3. Be able to squat without pain. 4. Be able to stand and sit without pain. 5. Be able to dance without pain. Below is the conditioning program I made utilizing the Block system from BASI Pilates approach and my patient s limitations and goals: Week 1- Patient to early post-op total knee replacement to perform any exercises in rehabilitation process. Week 2-4 BLOCK SYSTEM EQUIPMENT EXERCISES Warm up Mat Chest lift Leg lifts/leg changes Foot work Active range of motion measured at end of foot work and patient able to achieve 105 degrees of right knee flexion and -7 degrees of extension. Reformer with medium resistance Parallel Heels Parallel toes V position toes Open V position heels Open V position toes prehensile Calf raises Prancing AB work Reformer medium resistance Hundred Prep Hip Work Reformer light resistance Frogs Circles down Circles up Openings Spinal Articulation Mat Pelvic curl Stretches Mat and Thera-band Thera-band straight 7

9 leg hamstring stretch FBI (F/I) N/A Unable to perform at this time. Arm work Reformer Supine Arm Series: Extension Adduction Circles up Circles down Triceps FBI (A/M) N/A Unable to perform at this time. Leg work Magic circle Sitting series: Ankles Below knees Above knees Lateral Flexion/Rotation Mat Side lifts (Right knee not in full extension) Back Extension Reformer Breaststroke Prep Week 4-6 BLOCK SYSTEM EQUIPMENT EXERCISES Warm up Mat Cadillac Mat: Chest lift Leg lifts/leg changes Supine spine twist Pelvic Curl Cadillac: Roll up with roll up bar Foot work Active range of motion measured at end of foot work and patient able to achieve 112 degrees of right knee flexion and -3 degrees of extension. AB work Reformer with medium resistance Reformer medium resistance Wunda Chair Parallel Heels Parallel toes V position toes Open V position heels Open V position toes prehensile Calf raises Prancing Reformer: Hundred Prep Chair: 8

10 Standing Pike Hip Work Reformer medium resistance Frogs Extended frog Extended frog reverse Circles down Circles up Openings Spinal Articulation Reformer Bottom lift Stretches Mat and Thera-band Reformer Mat: Thera-band straight leg hamstring stretch Reformer: Standing lunge (with knee pad under surgical knee) FBI (F/I) Reformer Scooter Elephant Arm work Reformer Supine Arm Series: Extension Adduction Circles up Circles down Triceps FBI (A/M) N/A Unable to perform at this time Leg work Lateral Flexion/Rotation Magic circle Wunda Chair Mat Wunda chair Sitting series: Ankles Below knees Above knees Chair: Leg press standing Mat: Side lifts (Right knee in full extension) Chair: Side stretch Back Extension Reformer Breaststroke Prep Pulling straps 1 9

11 Week 6-8 BLOCK SYSTEM EQUIPMENT EXERCISES Warm up Mat Cadillac Mat: Chest lift Leg lifts/leg changes Supine spine twist Pelvic Curl Cadillac: Roll up with roll up bar Foot work Active range of motion measured at end of foot work and patient able to achieve 120 degrees of right knee flexion and 0 degrees of extension. AB work Reformer with heavy resistance Reformer medium resistance Wunda Chair Parallel Heels Parallel toes V position toes Open V position heels Open V position toes prehensile Calf raises Prancing SL heel SL Toes Reformer: Hundred Prep Hundreds Coordination Chair: Standing Pike Hip Work Cadillac Frog Circles down Circles up Walking Bicycles Single leg supine: Frog Circles up/down Hip extension Bicycle Spinal Articulation Reformer Bottom lift Stretches Reformer Reformer: Standing lunge (with knee pad under surgical knee) (Unable to perform kneeling lunge due to pain with 10

12 kneeling on surgical knee) FBI (F/I) Reformer Scooter Elephant Stomach massage round back Stomach massage flat back Arm work Reformer Arm Sitting Series: Chest expansion Biceps Rhomboids Hug-a-tree Salute FBI (A/M) N/A Unable to perform at this time Leg work Wunda Chair Leg press standing Lateral Flexion/Rotation Wunda chair Side stretch Back Extension Wunda Chair Swan Basic Week 8-12 BLOCK SYSTEM EQUIPMENT EXERCISES Warm up Mat Cadillac Mat: Double leg stretch Single leg stretch Cadillac: Roll up with roll up bar Foot work Active range of motion measured at end of foot work and patient able to achieve 120 degrees of right knee flexion and 0 degrees of extension. Reformer with heavy resistance Mini roll ups Parallel Heels Parallel toes V position toes Open V position heels Open V position toes prehensile Calf raises Prancing SL heel SL Toes AB work Reformer medium resistance Reformer: Hundred Prep Hundreds Coordination Hip Work Cadillac Frog 11

13 Circles down Circles up Walking Bicycles Single leg supine: Frog Circles up/down Hip extension Bicycle Spinal Articulation Reformer Bottom lift Bottom lift with extensions Stretches Reformer Reformer: Standing lunge (with knee pad under surgical knee) (Unable to perform kneeling lunge due to pain with kneeling on surgical knee) Side split FBI (F/I) Reformer Elephant Stomach massage reaching Long stretch Arm work Reformer Arm Sitting Series: Chest expansion Biceps Rhomboids Hug-a-tree Salute FBI (A/M) N/A Unable to perform at this time Leg work Cadillac Squats Lateral Flexion/Rotation Cadillac Side lift Back Extension Cadillac Prone 1 12

14 After 12 weeks of rehabilitation (3 times per week) Nancy met her short term and long term goals. Her progress/results are as follows: 1. Her active range of motion of her knee was at 125 degrees of flexion and 0 degrees of extension. Which is equal to her left knee and now allows her to perform all functional activities without pain or tissue limitations. 2. She currently has no complain of knee pain and or swelling. 3. Her right knee strength is graded a 4+/5 (Able to complete full range of motion with resistance against gravity) which is also equal to the left knee. 4. She has improved gait patterns with equal stride length and knee flexion bilaterally. 5. Improved static and dynamic balance. She is able to maintain a single legged stance on the right for 1 minute. The following pictures are of Nancy s knee after 12 weeks of rehabilitation showing full flexion and extension range of motion: To conclude this study, Nancy is very pleased with her results and is eager to continue with Pilates exercises to improve her strength, balance and flexibility. This study shows that Pilates based exercise is a great way to rehabilitate a total knee replacement due to the gravity eliminated foot work exercises and decreased stress on knee joints. After her 12 week program with me, Nancy went to her orthopedic surgeon for her follow up appointment and he stated 13

15 Your knee strength and range of motion is unbelievably great since after your surgery. You are really the poster child for a total knee replacement. That Pilates is really amazing. Bibliography 1. Jr,William C.Shiel. Total Knee Replacement: Surgery Pain, Recovery & Risks. MedicineNet, 10 Sept FNP, Kathleen Davis. The Knee: Anatomy, Injuries, Treatment, and Rehabilitation. Medical News Today, MediLexicon International, 18 Aug Isacowitz,Rael. Mat Movement Analysis Workbook. Costa Mesa, CA: Body Arts and Sciences international, Body Arts and Science International Isacowitz,Rael. Reformer Movement Analysis Workbook. Costa Mesa, CA: Body Arts and Sciences international, Body Arts and Science International Isacowitz,Rael. Cadillac Movement Analysis Workbook. Costa Mesa, CA: Body Arts and Sciences international, Body Arts and Science International Isacowitz,Rael. Wunda chair-ladder barrel Movement Analysis Workbook. Costa Mesa, CA: Body Arts and Sciences international, Body Arts and Science International