Effects of Balance Interventions on Elderly Patients after TKR

Kelsey Shelton

VCU DPT 2016

Overview

1. Present patient case from Clinical Education II

2. Ask a clinical question

3. Analyze available research

4. Answer the clinical question and relate to patient case

Patient History

• 76 y/o African American female

• Occupation: Retired

• PLOF: Community level with single point cane

• Independent in private residence

• Home Environment: One story house with 3 stairs to enter, bilateral rails

• Admitted to area hospital 5/19 for a L total knee replacement and admitted to skilled nursing facility 5/23

Diagnosis – Total Knee Replacement

• Procedure

• Risks/Complications

• Infection, blood clots, heart attack, stroke, nerve damage

• Recovery

• Average hospital stay – 3-5 days

• Physical therapy to restore function, strength, and ROM

• 1-2 months

Patient History

• Current Medical Hx:

• DM II, HTN, orthopnea, GERD, bilateral peripheral neuropathy in toes, atrial fibrillation

• PMHx

• R shoulder rotator cuff repair 2014, R TKR 2004

Patient Examination/Evaluation

Objective Findings:

• Pt was A&O x4, alert, cooperative

• Safety awareness – Good (safe for home alone, no cues for safety)

• AROM - LLE – knee flexion impaired (76°), knee extension impaired (+10°)

• Strength – RLE – 4/5, LLE – 3-/5

• Sitting Balance – Good

• Standing Balance – Fair

• Bed mobility – Mod I

• Functional transfers – Mod I

• Gait - 150 ft with one rest break

• Stairs – NT

Assessment

GaitSOB and complained of increased pain with ambulation

(8-9/10 VAS scale) Pt negotiated obstacles with CGA Functional Limitation – mobility: walking and moving around Participation Restrictions

Return to home independentPreform community level functional activityAttend Sunday sermon

Treatment Goals Pt goal STG - Patient will increase:

Standing balance to good in order to prepare for gait activities AROM of L knee flexion to 95° to facilitate patient’s ability to

perform ascending/descending 3 stairs with bilateral rails in order to safely return to private residence

L knee extension strength to 4+/5 in order to improve limb stability during gait

LTG: Pt will negotiate obstacles while ambulating with Mod I for

safety while turning in order to return to prior living and supervision levels

Interventions

LE strengthening in all positions

Balance activities Gait training Manual Pt education

Prognosis and Outcomes

Prognosis Good potential to progress towards goals due to prior PT

with R TKR and high prior level of function, good family support, and intact cognition

Outcomes Pt met all goals and was able to ambulate short distances

with SPC with supervision Pt discharged (20 visits) home alone with family support

and enrolled in outpatient orthopedic physical therapy

Clinical Question

Does improving balance in a 70 year old female patient with knee

osteoarthritis after a total knee replacement improve overall functional mobility as assessed through improved

performance on reliable and valid functional outcome measures?

Effects of balance training on functional outcome after total knee replacement in patients with knee osteoarthritis: a randomized

controlled trial Liao et al.

Clinical Rehabilitation, 2013

Objective: To evaluate the effectiveness of additional balance training on mobility and outcome in patients with knee osteoarthritis after a TKR

A prospective intervention study, randomized control trial 113 Participants – 50-85 y/o with tricompartmental,

cemented TKR Experimental group – functional training and additional

balance training vs. control

Liao et al.

Exclusion Criteria

Uncontrolled hypertension

Diabetes BMI > 40 kg/m2 Other lower extremity

orthopedic problems that limited the patient’s function

Neurological impairment

Functional Measures

Distance of functional forward reach

Single leg stance (eyes closed and open)

Sit-to-stand test Stair climbing test Timed 10m walk TUG WOMAC Osteoarthritis

Index

Liao et al.

Interventions

3x per week, one on one with PT

Training Routine (60 min) Warm-up Stretch Mobility exercises Muscle

strengthening Functional task

oriented exercises

Balance (90 min) Side stepping,

braiding, tandem walk, change direction, airex, BAPS, balance beam

Liao et al.

Results: Experimental group scores were significantly better

than those of the control group for all of the outcome measures (p<0.001)

Conclusion: For patients with knee OA receiving a TKR, eight weeks

of additional balance training can improve functional performance in mobility after surgery

An additional balance training program is recommended for the rehabilitation plan

Liao et al.

Limitations: Knee OA Lacked non-intervention control group – result of

natural return of muscle/physical function Dose effect asymmetry Time lapse

Liao et al.

Importance for my patient: Age Gender Knee OA, TKR Diabetes

Functional outcomes of outpatient balance training following total knee replacement in patients with knee osteoarthritis: a randomized

controlled trial Liao et al.

Clinical Rehabilitation, 2015

Objective: To evaluate whether balance training after total knee replacement surgery improves functional outcomes and to determine whether postoperative balance is associated with mobility

A prospective intervention study and randomized controlled trial Follow-up of earlier study – evaluate long term benefits

108 participants (only 5 did not return) Functional Measures

Liao et al.

Results: The balance rehabilitation group exhibited greater

improvement in balance, mobility, and functional outcomes in the 32-week follow-up assessment than the control group who received general functional training

Conclusion The administration of postoperative outpatient balance

training not only improves balance and mobility outcomes immediately after intervention, but also benefits six months after intervention

Liao et al.

Limitations Same authors and population Specific surgeon Lack of definition

Importance to my patient Effect on long term therapy Incorporation into POC

Does improving balance in a 70 year old female patient with knee osteoarthritis after a total knee replacement improve overall functional mobility as assessed

through improved performance on reliable and valid functional outcome measures?

Yes!

Effects of Balance Interventions on Elderly Patients after TKR

Questions?

References

Liao, C., Lin, L., Huang, Y., Huang, S., Chou, L., & Liou, T. (2015). Functional outcomes of outpatient balance training following total knee replacement in patients with knee osteoarthritis: a randomized controlled trial. Clinical Rehabilitation, 29(9), 855-867.

Liao, C., Liou, T., Huang, Y., & Huang, Y. (2013). Effects of balance training on functional outcome after total knee replacement in patients with knee osteoarthritis: a randomized controlled trial. Clinical Rehabilitation, 27(8), 697-709.