Considering a total knee replacement?

knee-replacement

Considering a total knee replacement?

 

There are increasing numbers of total knee replacements performed yearly. Medicare is initiating a bundled payment initiative for all facilities in 2017 and many are participating for the previous 2 years. What does this mean for the patients? Theoretically, it means more efficient care, with better outcomes, because patients will be more closely monitored. For instance, the hospital, and those employed by the hospital, stands to profit moreso than normal when patients have great success rates with more efficient care (see fewer visits performed).   From my perspective it is about 2 things: 1. Improve patient’s outcomes 2. Do this with less expense. Our country spends a large percentage of our money on healthcare, but when looked at from a broad perspective, we do a poor job of keeping our people healthy. Whatever the reason, this needs to change.

 

Those of us in healthcare understand that the insurance company drives the type of treatment that a patient can receive. Most patients, in my experience, will not pay out of pocket for care that they feel entitled to and will stop care when the entitlement is exhausted. We, as healthcare professionals, have to do a better job of demonstrating value to patients. I spend, like many people, over $1,500/year in order to have a cell phone with internet access. This amount of money would pay for 1 visit of PT per week for almost 6 months, if the patient paid out of pocket. BLASPHEMY! Why should I pay for something that the insurance company will cover?

 

The insurance companies are becoming more aware of our downfalls as a profession. One major downfall is one of the deadly sins…GREED! When patient’s have to take more responsibility for their own health care and have to share more of the costs of health care, then the patient will become more aware of how his/her dollars are being spent…or go broke in the process. Gratefully, I work for a company that doesn’t push profit as much as it pushes “right patient, right time, right treatment”. Patients need to see that not all therapy is the same and sometimes…just sometimes…the patient can have both high quality therapy at a low cost.

 

Bringing us to today’s post. Come and knock on our door…we’ve been waiting for your…and the kisses are hers and hers and his…three’s company too. When I think of single leg stance, I think of the flamingo stance. When I think of the flamingo stance, I think of terri/torrie/cindy (blond from the show) standing on one leg while at the zoo. Moral of the story is: patients with better balance do better overall. Patients can achieve better balance by working on the skill over time. Depending on the source, the NIH reports that it takes upwards of 50 hours of practice to improve balance. Go practice now.

 

Can you stand on one foot?

Can you do this with eyes closed?

Can you do this equally on both sides?

Can you do the eyes closed version for at least half as long as the eyes opened version?

 

If not, go see a PT. You can look at the APTA website or your state’s local website (Illinois Physical Therapy Association) in order to find a provider.

 

Piva SR, Gil AB, Almeida GJM, et al. A Balance Exercise Program Appears to Improve Function for Patients With Total Knee Arthroplasty: A Randomized Clinical Trial. Phys Ther. 2010;90:880-894.

 

Intro: 37% of TKA’s still have functional limitations p one year. Diminished walking speed, difficulty ascending/descending stairs, inability to return to sport are chief functional complaints. During TKA surgery several tendons, capsule, and remaining ligaments are retightened to restore the joint spaces deteriorated by the arthritis. Some of the knee ligaments are removed or released, which may affect mechanoreceptors/balance.

 

PURPOSE:

  1. To determine the feasibility of applying a balance exercise program in patients with TKA
  2. To investigate whether an F (functional) T (training) program supplemented with a balance exercise program (FT+B) could improve function compared to FT program alone
  3. To test the method and calculate a sample size for a future RCT with a larger sample size

 

METHOD: Double-blind pilot RCT (very strong evidence)

Inclusion: TKA in the previous 2-6 months (meaning not eligible for study if the TKA was before 2 months previous)

Exclusion: 2 or more falls in the previous year. Unable to ambulate 100 feet with an AD or rest period, acute illness or cardiac issues, uncontrolled HTN, severe visual impairment, LE amputation, progressive neurological disorder or pregnant (interesting exclusion criteria).

 

All went through a quadriceps muscle-sparing incision (cuts through the fascia of the patella instead of the quadriceps) this may be a factor in reducing rehab stay.

 

See the appendix for the protocol (6 weeks).

 

Testing measures:

  1. Self-selected gait speed (interesting, but probably not feasible for our clinic)
  2. Timed chair rise test (5 repetitions): easily added to our testing.
  3. single leg stance time: easily added in
  4. LEFS
  5. WOMAC

 

RESULTS:

  1. Adherence for both groups is 100% and the HEP adherence was similar (filled out logs)
  2. walking speed continued to improve over the course of 6 months for the FT+B group and was 25% better than the FT only group.
  3. The interesting fact is that improvement continued up to 6 months, when previous literature describes 3 months and done.
  4. Single leg stance: FT+B improved (as expected due to SAID), but the FT group either maintained or worsened on speed and balance.

 

DISCUSSION: FT+B demonstrates clinically important differences in walking speed, SLS, stiffness and pain, without adverse events. Subjects in the FT+B could balance on average 4 seconds longer than baseline. This may be important for weight bearing during the stance phase of walking. Performance-based measures should be used in place of subjective measures.

 

TAKE HOME: Patients will benefit from the addition of balance exercises post-surgically. It may be prudent to discuss with the surgeons of increasing the length of stay in therapy and decreasing the number of visits per week, as progress continues to occur past the 3 months initially surmised. Each patient should be tested with one or more of the following:

  1. SLS
  2. Chair rise test
  3. Gait speed: important indicator of function/independence/death
  4. Balance test (excluding Tinetti due to possible ceiling affect when the patient no longer needs an AD).

Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

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