ORIGINAL ARTICLE INTRODUCTION

Size: px
Start display at page:

Download "ORIGINAL ARTICLE INTRODUCTION"

Transcription

1 Arthritis & Rheumatism (Arthritis Care & Research) Vol. 61, No. 2, February 15, 2009, pp DOI /art , American College of Rheumatology ORIGINAL ARTICLE Improved Function From Progressive Strengthening Interventions After Total Knee Arthroplasty: A Randomized Clinical Trial With an Imbedded Prospective Cohort STEPHANIE C. PETTERSON, 1 RYAN L. MIZNER, 2 JENNIFER E. STEVENS, 3 LEO RAISIS, 4 ALEX BODENSTAB, 4 WILLIAM NEWCOMB, 4 AND LYNN SNYDER-MACKLER 1 Objective. To determine the effectiveness of progressive quadriceps strengthening with or without neuromuscular electrical stimulation (NMES) on quadriceps strength, activation, and functional recovery after total knee arthroplasty (TKA), and to compare progressive strengthening with conventional rehabilitation. Methods. A randomized controlled trial was conducted between July 2000 and November 2005 in an academic outpatient physical therapy clinic. Two hundred patients who had undergone primary, unilateral TKA for knee osteoarthritis were randomized to 1 of 2 interventions 4 weeks after surgery, and 41 patients eligible for enrollment who did not participate in the intervention were tested 12 months after surgery (standard of care group). All randomized patients received 6 weeks of outpatient physical therapy 2 or 3 times per week through 1 of 2 intervention protocols: an exercise group (volitional strength training) or an exercise-nmes group (volitional strength training and NMES). Treatment effects were evaluated by a burst superimposition test to assess quadriceps strength and volitional activation 3 and 12 months postoperatively. The Medical Outcomes Study Short Form 36 and Knee Outcome Survey were completed. Knee range of motion, Timed Up and Go, Stair-Climbing Test, and 6-Minute Walk were also measured. Results. Strength, activation, and function were similar between the exercise and exercise-nmes groups at 3 and 12 months. The standard of care group was weaker and exhibited worse function at 12 months compared with both treatment groups. Conclusion. Progressive quadriceps strengthening with or without NMES enhances clinical improvement after TKA, achieving similar short- and long-term functional recovery and approaching the functional level of healthy older adults. Conventional rehabilitation does not yield similar outcomes. INTRODUCTION ClinicalTrials.gov identifier: NCT Supported by the NIH (grant R01-HD041055). 1 Stephanie C. Petterson, PhD, MPT, Lynn Snyder- Mackler, ScD, PT, ATC, FAPTA: University of Delaware, Newark; 2 Ryan L. Mizner, PhD, MPT: Eastern Washington University, Spokane; 3 Jennifer E. Stevens, PhD, MPT: Health Sciences Center and University of Colorado at Denver; 4 Leo Raisis, MD, Alex Bodenstab, MD, William Newcomb, MD: First State Orthopaedics, Newark, Delaware. Address correspondence to Lynn Snyder-Mackler, ScD, PT, ATC, FAPTA, University of Delaware, 301 McKinly Laboratory, Newark, DE smack@udel.edu. Submitted for publication February 20, 2008; accepted in revised form October 6, Knee osteoarthritis (OA) results in persistent pain, limited function, and poor quality of life (1). In the US, nearly 500,000 total knee arthroplasties (TKAs) are performed each year for severe knee OA (2). Candidates for this procedure have radiographic evidence of joint damage, moderate to severe persistent pain, and clinically significant functional limitations that diminish quality of life (3). TKA reliably alleviates pain and improves self-reported function, yet patients continue to exhibit marked impairments in quadriceps strength, voluntary muscle activation, and functional performance (e.g., walking, stair climbing) (4,5). A 60% reduction in quadriceps strength is evident 1 month after surgery; volitional muscle activation, explaining more of the quadriceps strength loss than cross-sectional area, is reduced by 17% (6). Functional performance is reported to worsen by 20 25% 1 month after TKA (7). These deficits in strength and function do not resolve spontaneously. Most recover to preoperative status; however, impairments in strength and function remain below healthy age-matched populations for years after TKA (4,8). Progressive rehabilitation targeting these deficits has not been systematically studied and is not routinely prescribed. A recent meta-analysis found short-term benefit 174

2 Strengthening Interventions After Total Knee Arthroplasty 175 but no long-term advantage of structured rehabilitation; however, only 6 studies included primary outcomes of pain, range of motion (ROM), and self-reported function (9). In addition, a National Institutes of Health sponsored consensus development conference on TKA concluded that the use of rehabilitation services is one of the most understudied aspects of the perioperative management of patients following total knee replacement and there is no evidence supporting the generalized use of any specific preoperative or postoperative rehabilitation interventions (10). Numbers of primary TKAs per year in the US (478,000 in 2004, the last year for which the National Hospital Discharge Survey data are available) (2) have exceeded predictions of just 5 years ago for the year Since the consensus conference, there have been no studies that have investigated vigorous therapeutic exercise regimens and documented intensity, frequency, and functional- and impairment-based outcomes. Neuromuscular electrical stimulation (NMES) has been used in other populations to successfully target quadriceps dysfunction (11 13). Several case studies have demonstrated the potential of NMES to enhance the recovery of muscle strength and muscle function in persons after TKA (14 16). It has been hypothesized that NMES preferentially targets the larger force-producing type II muscle fibers, resulting in greater strength gains and reversal of activation deficits (17 19). We investigated whether the addition of NMES to a progressive volitional strength training program would improve the recovery of quadriceps strength, volitional muscle activation, and function following TKA in a single-blind, randomized clinical trial (RCT). Our primary hypothesis was that NMES combined with a progressive volitional strength training program would yield greater gains in strength, activation, and function 3 and 12 months after TKA than a progressive volitional strength training program alone. We also hypothesized that patients treated with a combination of NMES and progressive strength training would achieve better self-report of function, ROM, and pain scores than would patients participating in progressive strength training alone. In an imbedded prospective cohort study, our primary hypothesis was that patients participating in progressive strength training (with or without NMES) would have greater muscle strength, activation, and function, but similar ROM, pain, and self-report scores 12 months after TKA than a cohort receiving the standard of care in the community. We believe that a rehabilitation program specifically designed to counter age, OA, and postsurgical-related changes to the neuromuscular system will improve impairment and functionally based outcomes after TKA. PATIENTS AND METHODS Patients. Individuals ages years scheduled to undergo unilateral TKA by 3 experienced local orthopedic surgeons were considered candidates for study inclusion and were mailed study information. A total of 1,093 individuals were scheduled for TKA between July 2000 and November A telephone interview to determine eligibility was conducted if potential candidates responded to the mailings and expressed interest in participation. Patients were excluded if they had 1) uncontrolled hypertension, 2) diabetes, 3) body mass index (BMI) 40 kg/m 2 (20), 4) symptomatic OA in the contralateral knee (defined as self-reported knee pain 4 on a 10-point verbal analog scale), 5) other lower extremity orthopedic problems limiting function, 6) neurologic impairment, or 7) a residence outside of a 20-mile radius of the clinic. All patients underwent a tricompartmental, cemented TKA with a medial parapatellar surgical approach and received inpatient rehabilitation and home physical therapy prior to enrollment. Patients of 1 referring surgeon (LR) who met all criteria but were unable to participate in the RCT and agreed to be tested 12 months after TKA were recruited to represent the standard of care in the community (standard of care group) as a comparison cohort to the referring surgeon s (LR) RCT cohort. This study was approved by the Human Subject Review Board at the University of Delaware and was in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to participation. This study was conducted at the University of Delaware Physical Therapy Clinic, a public, not-for-profit institution. Intervention. Treatment began 3 4 weeks after TKA. Eligible participants completed a baseline study evaluation and a comprehensive clinical evaluation by 2 independent licensed physical therapists. Following the clinical evaluation, patients were enrolled into outpatient rehabilitation at the University of Delaware Physical Therapy Clinic, group assignment was revealed to the participant, and the treatment intervention was initiated. One hundred participants were randomized to a progressive volitional strength training program (exercise group) and 100 participants were randomized to a combined NMES and volitional strength training program (exercise-nmes group) (Figure 1 and Table 1). Both groups received outpatient physical therapy 2 or 3 times per week for 6 weeks with a minimum requirement of 12 therapy visits. The rehabilitation protocol was centered on an impairment-based model described by Stevens et al (15). The novel components of the intervention were the progressive nature of the strengthening exercises and the addition of NMES. Interventions targeting knee extension and flexion ROM, patellar mobility, quadriceps strength, pain control, and gait were included in both programs. The volitional strength training program specifically targeted the quadriceps femoris muscle group. Intensity and type of strengthening exercises were based on the individual s initial clinical evaluation and followup assessments. In addition to the quadriceps, exercises targeted the hamstrings, gastrocnemius, soleus, hip abductors, and hip flexors (15). Exercises were initiated with 2 sets of 10 repetitions and then progressed to 3 sets of 10 repetitions. Weights were increased to maintain a 10-repetition maximum targeted intensity level. The NMES component consisted of 10 electrically elicited contractions of the quadriceps femoris muscle. Patients were seated in an electromechanical dynamometer

3 176 Petterson et al assist or volitionally contract their muscle during the electrical stimulation. Procedural reliability. Procedural reliability was assessed for each patient once during the course of rehabilitation by a physical therapist not involved in the patient s care. The number of steps correctly completed in the protocol was divided by the total number of protocol steps and multiplied by 100. Mean SD procedural reliability for the exercise group was 92% 8% and for the exercise- NMES group was 93% 9%. Figure 1. Consolidated Standards of Reporting Trials group diagram. BMI body mass index; NMES neuromuscular electrical stimulation. (KinCom; Chattanooga Corporation, Chattanooga, TN) with the knee stabilized at 60 of knee flexion. Two cm self-adhesive electrodes (ConMed, Utica, NY) were placed over the rectus femoris muscle belly proximally and the vastus medialis muscle belly distally. Stimulation was characterized by a 2,500-Hz, sinusoidal, alternating waveform current at 50 bursts per second for 10 seconds, plus a 2-second ramp on time with an 80-second rest period between contractions (Versastim 380; Electro Med Health Industries, Miami Beach, FL) (21). Current amplitude was raised to the patient s maximum tolerance. The target intensity was a minimum electrically-elicited force output of 30% of the patient s daily maximal volitional isometric contraction (MVIC) force. Patients did not Testing. All followup assessments were performed 3 months and 12 months after TKA by investigators blinded to treatment group assignment. Baseline and followup study evaluations were completed during a 90-minute session that included health questionnaires, active knee ROM, Timed Up and Go (TUG), Stair-Climbing Test (SCT), quadriceps strength and activation testing, and 6-Minute Walk (6MW). Subjects completed functional and health questionnaires prior to strength and functional testing. The standard of care group was assessed once 12 months postoperatively. Primary outcome measures. Quadriceps strength and activation testing. Quadriceps strength and volitional muscle activation were measured using a burst superimposition technique (22), which is a validated quadriceps strength assessment widely used in a variety of populations with and without knee pathologies (6,23 26). Briefly, subjects knees were stabilized in 75 of flexion on a dynamometer (KinCom). A supramaximal burst of electrical stimulus was administered during a 3 5-second MVIC (Grass 8800; Grass Instruments, Warwick, RI). The testing procedure was repeated a maximum of 3 times for each leg if incomplete recruitment was evident. Data were collected and analyzed using custom written software (LabView; National Instruments, Austin, TX). Muscle activation was calculated using a modification of the central activation ratio (CAR) method that accounts for the tendency of the CAR to overestimate activation (22,27). Table 1. Baseline demographics of the RCT population and 1-year characteristics of the standard of care and RCT cohorts* RCT comparison Cohort comparison Characteristic Exercise (n 100) Exercise-NMES (n 100) P RCT (n 41) Standard of care (n 41) P Women, % Age at surgery, years Height, meters Weight, kg BMI, kg/m Quality of life (SF-36) PCS MCS Physical therapy visits * Values are the mean SD unless otherwise indicated. RCT randomized clinical trial; NMES neuromuscular electrical stimulation; BMI body mass index; SF-36 Short Form 36; PCS physical component score; MCS mental component score. Significant by t-test or chi-square test.

4 Strengthening Interventions After Total Knee Arthroplasty 177 The CAR is calculated by dividing MVIC by the electricallyaugmented force. The trial with the largest quadriceps MVIC force was normalized to BMI (NMVIC; newtons/ BMI) for data analysis. Functional measures. The TUG, SCT, and 6MW were used to assess functional performance. The TUG measures the time to rise from a seated position in an armed chair (seat height 46 cm), walk 3 minutes, turn around, and return to a seated position in the chair (R intrarater 0.95, R interrater 0.98) (28,29). The SCT measures the time to ascend and descend 12 steps (height 7.9 cm; R 0.90) (30,31). For both the TUG and SCT, the average of 2 trials was analyzed. The 6MW measures the distance a person can walk in 6 minutes (R 0.94) (31 33). Participants were allowed use of an assistive device and were instructed to move as quickly as they felt safe and comfortable. Secondary outcome measures. Self-assessment questionnaires. The Medical Outcomes Study Short Form 36 (SF-36) (34) and the Knee Outcome Survey Activities of Daily Living scale (KOS ADLS) (35) were administered to measure perceived functional ability (R 0.92) (35). Both the mental and physical component scores of the SF-36, which are reliable measures of health status in patients with OA (36), were computed. Knee ROM. Active knee flexion and extension ROM were measured in the supine position with a long axis goniometer (37). Positive values indicate positions of knee flexion and negative values indicate positions of knee hyperextension (R c flexion 0.96, R c extension 0.81) (38). Knee pain. Knee pain (pain KOS) was measured with a question on the KOS ADLS: How does pain affect the function of your knee during daily activities? Scores ranged from 0 (pain prevents me from all activities) to 5 (pain has no effect on daily activities). Statistical analysis. Data were processed using SPSS statistical software, version 15.0 (SPSS, Chicago, IL). Independent-sample t-tests were used to compare the randomized groups at baseline. Primary and secondary outcome variables were analyzed using a repeated-measures analysis of covariance with time as the repeated-measures factor (3 and 12 months), rehabilitation group (exercise versus exercise-nmes) as the between-groups factor, and baseline score as the covariate. An intent-to-treat approach was adopted (39). Independent-sample t-tests were used to compare the RCT cohort and the standard of care group at 12 months. Effect size was quantified using Cohen s d (mean difference between groups divided by the pooled SD) (40). The modified Hochberg procedure, which has the highest power among accepted modified Bonferroni techniques, was used to adjust our probability level of 0.05 for multiple comparisons (41). Hierarchical linear regression analysis was used to determine the predictors (independent variables: NMVIC, pain KOS, flexion ROM, extension ROM) of functional performance (dependent variables: TUG, SCT, 6MW) at 12 months. Four models were considered: model 1 included only NMVIC; model 2 for TUG and SCT included NMVIC and knee flexion ROM, and model 2 for 6MW included NMVIC and knee extension ROM; model 3 included pain KOS in addition to the model 2 predictors; and model 4 included all 4 independent variables. The F test was used to analyze the significance of the resultant change in R 2 with the addition of each independent variable to the regression model. Clinical reasoning was used to determine order of variable inclusion into the models based on each variable s importance to the functional task. RESULTS No adverse events were related to the exercise intervention. Only 1 patient reported feeling dizzy and lightheaded following the first NMES treatment. Three subjects in the exercise group and 16 patients in the exercise-nmes group did not complete treatment (Figure 1). There was no significant difference between the exercise group and the exercise-nmes group in total number of treatment visits (P 0.25) (Table 1). The groups attended a pooled mean SD of visits (range 12 18); only 11 patients completed 15 visits. Comparisons between the randomized groups. There were no significant differences between the exercise and exercise-nmes groups on any outcome measure at 3 or 12 months (P 0.08 for all after adjustment for baseline values) (Table 2). Both groups significantly improved on all measures from baseline to 3 months and from 3 12 months (P for all) with the exception of the mental component score of the SF-36, which only improved from 0 3 months (Table 2). Cohort comparison. The exercise and exercise-nmes groups (RCT cohort) were not significantly different in any primary and secondary outcome measure at 12 months, and their baseline demographics were similar. Therefore, the data from all of the referring surgeon s (LR) patients in the RCT cohort (n 41) were compared with the cohort of his patients representing the standard of care in the community (n 41). The standard of care group had more physical therapy sessions than the RCT cohort (P 0.001) (Table 1). At 12 months, the RCT cohort was significantly stronger than the standard of care group (P 0.007). Mean NMVIC was 21% less in the standard of care cohort compared with the RCT cohort. The standard of care group also exhibited worse functional performance at 12 months. The standard of care group took 24% longer on the TUG (P 0.004), 44% longer to complete the SCT (P 0.001), and walked a 15% shorter distance on the 6MW (P 0.003) (Figure 2). There was no significant difference between the standard of care group and the RCT cohort on any of the secondary outcome measures of the SF-36 physical component score, KOS score, pain KOS score, knee flexion ROM, knee extension ROM, or voluntary muscle activation (P 0.01 for all). Progressive strength training following TKA had a moderate effect on quadriceps strength (effect size d 0.63;

5 178 Petterson et al Table 2. Mean of primary and secondary outcome measures and percent change in assessment scores in the randomized groups* Exercise group Exercise-NMES group Variables 0 months (n 100) 3 months (n 92) 12 months (n 81) 0 3 months 3 12 months 0 12 months 0 months (n 100) 3 months (n 76) 12 months (n 68) 0 3 months 3 12 months 0 12 months SF-36 PCS SF-36 MCS KOS ADLS Pain KOS Timed Up and Go, seconds Stair-Climbing Test, seconds Six-Minute Walk, meters NMVIC, newtons/bmi CAR Flexion ROM, degrees Extension ROM, degrees * Both groups significantly improved from 0 3 months and from 3 12 months on all measures. There were no significant differences between the exercise group and the exercise-nmes group at any time point. NMES neuromuscular electrical stimulation; SF-36 Short Form 36; PCS physical component score; MCS mental component score; KOS ADLS Knee Outcome Survey Activities of Daily Living scale; NMVIC normalized maximum voluntary isometric contraction; BMI body mass index; CAR central activation ratio; ROM range of motion. Not significantly different from 3 months.

6 Strengthening Interventions After Total Knee Arthroplasty 179 Figure 2. Comparison between randomized clinical trial (RCT) cohort and standard of care cohort. A, Timed Up and Go (TUG) and Stair-Climbing Test (SCT) performance. B, 6-Minute Walk (6MW) distance. C, Normalized maximal volitional isometric contraction (NMVIC). The standard of care group performed significantly worse than the RCT cohort on all performance measures. Error bars represent the SD. * P m meters. 95% confidence interval [95% CI] 1.26, 7.50), TUG performance (effect size d 0.69; 95% CI 3.04, 0.58), and 6MW performance (effect size d 0.70; 95% CI 93, 442), and had a large effect on SCT performance (effect size d 0.86; 95% CI 8.06, 2.44). Predictors of function at 12 months. Timed Up and Go. The predictive model that included NMVIC, flexion ROM, pain KOS score, and extension ROM explained 28% of the variability in TUG performance (R , P 0.001). Quadriceps strength was the strongest predictor of TUG performance (R , P 0.001). Flexion ROM significantly added to the predictive model (R , P 0.001), whereas neither pain nor extension ROM significantly added to the model (Table 3). Stair-Climbing Test. The predictive model that included NMVIC, flexion ROM, pain KOS score, and extension ROM explained 26% of the variability in SCT performance (R , P 0.001). Quadriceps strength was the single strongest predictor of SCT performance (R , P 0.001). The addition of flexion ROM, pain, and extension ROM did not contribute significantly to the predictive model (Table 3). Six-Minute Walk. The predictive model that included NMVIC, extension ROM, pain KOS score, and flexion ROM explained 37% of the variability in 6MW performance (R , P 0.001). Quadriceps strength was the single strongest predictor of 6MW performance (R , P 0.001). The addition of flexion ROM, pain, and extension ROM did not contribute significantly to the model (Table 3). DISCUSSION This RCT investigated the use of 2 rehabilitation protocols, a progressive strength training program and a combined Table 3. Hierarchical regression models used to predict functional performance 12 months after total knee arthroplasty* Model R R 2 R 2 change F change P Timed Up and Go Quadriceps strength Quadriceps strength flexion ROM Quadriceps strength flexion ROM pain KOS Quadriceps strength flexion ROM pain KOS extension ROM Stair-Climbing Test Quadriceps strength Quadriceps strength flexion ROM Quadriceps strength flexion ROM pain KOS Quadriceps strength flexion ROM pain KOS extension ROM Six-Minute Walk Quadriceps strength Quadriceps strength extension ROM Quadriceps strength extension ROM pain KOS Quadriceps strength extension ROM pain KOS flexion ROM * ROM range of motion; KOS Knee Outcome Survey Activity of Daily Living scale. P 0.01.

7 180 Petterson et al Table 4. Comparison of function measures with published data of controls and patients who underwent total knee arthroplasty* 3 months 12 months Control Knee flexion range of motion, degrees Kramer et al, 2003 (44) Kumar et al, 1996 (50) 115 Rajan et al, 2004 (51) Ranawat et al, 2003 (52) 119 Walsh et al, 1998 (4), F/M 114/ /142 Current study Exercise Exercise-NMES Standard of care 120 Timed Up and Go, seconds Steffen et al, 2002 (46) Age years 8.00 Age years 9.00 Age years Stratford et al, 2003 (53) 12.3 Current study Exercise Exercise-NMES Standard of care 9.01 Stair-Climbing Test, seconds Stratford et al, 2003 (53) 23.5 Walsh et al, 1998 (10 steps) (4), F/M 31.1/ /11.81 Current study Exercise Exercise-NMES Standard of care Six-Minute Walk, meters Enright and Sherrill, 1998 (54), F/M 494/576 Kramer et al, 2003 (44) Moffet et al, 2004 (45) Usual care Functional rehabilitation Steffen et al, 2002 (46), F/M Age years 538/572 Age years 471/527 Age years 392/417 Current study Exercise Exercise-NMES Standard of care 462 * NMES neuromuscular electrical stimulation. NMES and progressive strength training program, in the postoperative management of individuals following primary, unilateral TKA for knee OA. Results were also compared with a cohort of individuals who received the standard of care for rehabilitation after TKA. The individuals in the study were typical of the population of individuals undergoing TKA, exhibiting profound impairments in quadriceps strength and volitional muscle activation following surgery (6,42,43). There were no significant differences on any outcome variable between the arms of the RCT, but both the exercise group and the exercise-nmes group demonstrated significant improvements in quadriceps strength and muscle activation, functional performance, and self-report of function during the rehabilitation period and 12 months after surgery. Importantly, both the exercise and exercise-nmes groups in the single surgeon prospective cohort comparison demonstrated substantially greater quadriceps strength and functional performance 12 months postoperatively than the standard of care group. Comparing outcomes of this RCT with published outcomes after TKA and healthy older adults highlights the superior results achieved by both treatment arms (4,44,45) (Table 4). Walsh et al measured stair-climbing time (ascent and descent of 10 stairs) in 29 individuals 1 year after TKA (4). Mean SD stair-climbing time reported was seconds, 46% slower than age-matched controls ( seconds). Mean stair-climbing time of RCT participants (ascent and descent of 12 stairs) was seconds 12 months postoperatively, equivalent to the control subjects in the study by Walsh et al, and 47% faster than their subjects with TKA. Furthermore, the number of

8 Strengthening Interventions After Total Knee Arthroplasty 181 individuals in our study that used an assistive device during the performance assessments decreased; no subjects used an assistive device on either the TUG or SCT at 3 or 12 months, and only 1 used an assistive device at 3 and 12 months on the 6MW. Few studies have investigated the effectiveness of rehabilitation after TKA (5,44). Kramer et al compared the outcomes of a home-based program and a clinic program over a 1-year period (44). Although there was no difference between the 2 treatment groups, the recovery of patients in their study was much slower than our patients. In the 6MW, subjects in our trial walked 212 meters further 3 months postoperatively and 150 meters further 12 months postoperatively. Our subjects had 10 more knee flexion at 12 months (Table 4). Similarly, Moffet et al compared a functional rehabilitation program with customary care (5). Their results support our argument that intensive rehabilitation improves function after TKA. However, their program with similar patients was not as successful; subjects in their study walked 145 meters less on the 6MW 12 months after TKA (Table 4). We demonstrated that quadriceps strength was the strongest predictor of function at 1 year. Moffet et al did not target quadriceps strength in their intervention. The addition of progressive exercises and NMES specifically aimed at strengthening the quadriceps femoris may have resulted in greater functional ability in our study cohort. A review of the literature and comparison with our prospective standard of care cohort illustrates the lack of consensus regarding rehabilitation after TKA even within a single surgeon s practice. The standard of care group attended more outpatient physical therapy visits (range 0 46 visits). By the standards typically used to describe the success of TKA (pain, knee flexion ROM, and patient self-report), the standard of care group did as well as the RCT intervention groups and were similar to patient outcomes reported in the literature; however, in the areas of strength and function, the standard of care group performed much more poorly and their functional performance was well below reported norms of healthy individuals (4,5,46). The standard of care group took 1.5 seconds longer to complete the TUG, 4.5 seconds longer to complete the SCT, and walked 90 meters less on the 6MW than healthy older adults in 2 other studies (46,47). Review of the physical therapy records of the standard of care cohort revealed a primary focus on ROM exercise, stationary cycling, and various straight-leg raising exercises without weights. The inconsistency of care in both the number of visits and nature of exercises most likely contributes to the difference in outcomes observed. Our data suggest that individuals who do not undertake an intensive rehabilitation program following TKA are clearly at a disadvantage. Quadriceps strength is related to functional performance (7,30), and it was the single greatest predictor of function in our sample (rising from a chair, stair climbing, and walking distance). Functional performance peaks 3 years after surgery and slowly declines in the subsequent 10- year period (8). Therefore, inadequate strength recovery following TKA holds several implications. Moderate to strong effect sizes for all functional measures and strength favored the intervention groups. The largest effect of the intervention was on the SCT, which places the highest demand on the quadriceps. Stair climbing is the single largest residual dysfunction after TKA and the ability to climb stairs worsens over time (8). Failing to obtain adequate functional recovery may accelerate functional decline and predispose these individuals to an early loss of functional independence as they age. Both the exercise and exercise-nmes groups exceeded the best previously reported functional performance scores at 1 year (4,45) (Table 4). The difference in our intervention was the addition of a progressive quadriceps strengthening program. Functional decline may be delayed with adequate quadriceps strength training; followup of these patients continues to discern the long-term impact of the implemented strengthening interventions. In addition, many of these studies used knee ROM as an outcome measure; however, evidence suggests that ROM does not strongly correlate with function (30). On the other hand, performance measures accurately portray functional status and are sensitive to changes with postoperative recovery (31). Quadriceps strength is also more strongly correlated with functional performance (7); therefore, we would recommend that both strength and function be used to assess rehabilitation outcomes. The primary etiology of early quadriceps strength loss after TKA is voluntary activation failure (48). We predicted that the addition of NMES would result in better quadriceps strength, activation, and function than a progressive exercise program alone, but this hypothesis was not supported. Both programs resulted in improved activation, and consequently strength improved over time, translating to better function. Similar findings were reported by Hurley and Newham, who demonstrated improvement in voluntary muscle activation in persons with knee OA using isokinetic and isometric strengthening exercises (49). In conjunction with Hurley and Newham, our results suggest that activation deficits do not undermine the effectiveness of progressive volitional strength training. There were limitations to the present study. Although the dropout rate may raise concerns, we planned for a 20% dropout rate and our a priori power analysis indicated that 30 subjects would be needed in each treatment arm to demonstrate a treatment effect. The NMES treatment was uncomfortable for some and accounted for the higher dropout rate in this group. Only 1 subject in the exercise group dropped out because of poor tolerance for the exercise regimen, whereas 11 of the 16 participants who dropped out of the exercise-nmes group did not complete their interventions because they reported the NMES treatment to be too uncomfortable. Second, the standard of care group was not randomized, but rather was comprised of individuals who agreed to complete the 12-month assessment and gave permission for their rehabilitation records to be reviewed. We used this protocol in order to compare patients treated by the same surgeon using the same technique; the standard of care group was referred to various local facilities for outpatient physical therapy. In summary, there were no significant or clinically meaningful differences between the 2 interventions. Both 6-week rehabilitation programs after TKA emphasized

9 182 Petterson et al progressive quadriceps strengthening and resulted in better functional outcomes than a cohort that received the standard of care. Furthermore, outcomes exceeded those previously reported in the literature, approaching the function of age-matched healthy older adults. ACKNOWLEDGMENTS We wish to acknowledge the expertise of the physical therapists at the University of Delaware Physical Therapy Clinic. AUTHOR CONTRIBUTIONS Dr. Snyder-Mackler had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study design. Petterson, Mizner, Stevens, Raisis, Bodenstab, Newcomb, Snyder-Mackler. Acquisition of data. Petterson, Mizner, Stevens, Snyder-Mackler. Analysis and interpretation of data. Petterson, Mizner, Stevens, Snyder-Mackler. Manuscript preparation. Petterson, Mizner, Stevens, Raisis, Bodenstab, Newcomb, Snyder-Mackler. Statistical analysis. Petterson, Snyder-Mackler. REFERENCES 1. Guccione AA, Felson DT, Anderson JJ, Anthony JM, Zhang Y, Wilson PW, et al. The effects of specific medical conditions on the functional limitations of elders in the Framingham Study. Am J Public Health 1994;84: National Center for Health Statistics, US Department of Health and Human Services, Centers for Disease Control and Prevention. National Hospital Discharge Survey : number of patients, number of procedures, average patient age, average length of stay. In: Data extracted and analyzed by American Academy of Orthopaedic Surgeons. Washington, DC: Department of Research and Scientific Affairs; American Academy of Orthopedic Surgeons. Total knee replacement Walsh M, Woodhouse LJ, Thomas SG, Finch E. Physical impairments and functional limitations: a comparison of individuals 1 year after total knee arthroplasty with control subjects. Phys Ther 1998;78: Moffet H, Collet JP, Shapiro SH, Paradis G, Marquis F, Roy L. Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: a singleblind randomized controlled trial. Arch Phys Med Rehabil 2004;85: Stevens JE, Mizner R, Snyder-Mackler L. Quadriceps strength and volitional activation before and after total knee arthroplasty for osteoarthritis. J Orthop Res 2003;21: Mizner RL, Petterson SC, Snyder-Mackler L. Quadriceps strength and the time course of functional recovery after total knee arthroplasty. J Orthop Sports Phys Ther 2005;35: Ritter MA, Thong AE, Davis KE, Berend ME, Meding JB, Faris PM. Long-term deterioration of joint evaluation scores. J Bone Joint Surg Br 2004;86: Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ 2007;335: National Institute of Health. NIH consensus development conference on total knee replacement: final statement. NIH Consensus Development Program; 2003 Dec 8 10; Bethesda, MD. Bethesda (MD): NIH; Fitzgerald GK, Piva SR, Irrgang JJ. A modified neuromuscular electrical stimulation protocol for quadriceps strength training following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2003;33: Snyder-Mackler L, Delitto A, Bailey S, Stralka S. Strength of quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament: a prospective, randomized clinical trial of electrical stimulation. J Bone Joint Surg Am 1995;77: Delitto A, Rose SJ, McKowen JM, Lehman RC, Thomas JA, Shively RA. Electrical stimulation versus voluntary exercise in strengthening thigh musculature after anterior cruciate ligament surgery. Phys Ther 1988;68: Lewek M, Stevens J, Snyder-Mackler L. The use of electrical stimulation to increase quadriceps femoris muscle force in an elderly patient following a total knee arthroplasty. Phys Ther 2001;81: Stevens JE, Mizner R, Snyder-Mackler L. Neuromuscular electrical stimulation for quadriceps muscle strengthening after bilateral total knee arthroplasty: a case series. J Orthop Sports Phys Ther 2004;34: Petterson S, Snyder-Mackler L. The use of neuromuscular electrical stimulation to improve activation deficits in a patient with chronic quadriceps strength impairments following total knee arthroplasty. J Orthop Sports Phys Ther 2006;36: Sinacore DR, Delitto A, King DS, Rose SJ. Type II fiber activation with electrical stimulation: a preliminary report. Phys Ther 1990;70: Cabric M, Appell HJ, Resic A. Fine structural changes in electrostimulated human skeletal muscle: evidence for predominant effects on fast muscle fibres. Eur J Appl Physiol Occup Physiol 1988;57: Binder-Macleod SA, Halden EE, Jungles KA. Effects of stimulation intensity on the physiological responses of human motor units. Med Sci Sports Exerc 1995;27: Centers for Disease Control and Prevention. BMI for adults: what does this all mean? In: Department of Health and Human Services, Centers for Disease Control and Prevention, editors. World Health Organization. BMI classification in global database on body mass index. URL: index.jsp?intropage itro_3.html. 21. Snyder-Mackler L, Delitto A, Stralka SW, Bailey SL. Use of electrical stimulation to enhance recovery of quadriceps femoris muscle force production in patients following anterior cruciate ligament reconstruction. Phys Ther 1994;74: Kent-Braun JA, Le Blanc R. Quantitation of central activation failure during maximal voluntary contractions in humans. Muscle Nerve 1996;19: Stevens JE, Binder-Macleod S, Snyder-Mackler L. Characterization of the human quadriceps muscle in active elders. Arch Phys Med Rehabil 2001;82: Lewek M, Rudolph K, Snyder-Mackler L. Quadriceps femoris muscle weakness and activation failure in patients with symptomatic knee osteoarthritis. J Orthop Res 2004;22: Manal TJ, Snyder-Mackler L. Failure of voluntary activation of the quadriceps femoris muscle after patellar contusion. J Orthop Sports Phys Ther 2000;30: Snyder-Mackler L, De Luca PF, Williams PR, Eastlack ME, Bartolozzi AR 3rd. Reflex inhibition of the quadriceps femoris muscle after injury or reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am 1994;76: Stackhouse SK, Stevens JE, Johnson CD, Snyder-Mackler L, Binder-Macleod SA. Predictability of maximum voluntary isometric knee extension force from submaximal contractions in older adults. Muscle Nerve 2003;27: Podsiadlo D, Richardson S. The timed up & go : a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39: Piva SR, Fitzgerald GK, Irrgang JJ, Bouzubar F, Starz TW. Get up and go test in patients with knee osteoarthritis. Arch Phys Med Rehabil 2004;85: Mizner RL, Petterson SC, Stevens JE, Axe MJ, Snyder-Mackler L. Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty. J Rheumatol 2005; 32:

10 Strengthening Interventions After Total Knee Arthroplasty Kennedy DM, Stratford PW, Wessel J, Gollish JD, Penney D. Assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty. BMC Musculoskelet Disord 2005;6: Enright PL. The six-minute walk test. Respir Care 2003;48: Kervio G, Carre F, Ville NS. Reliability and intensity of the six-minute walk test in healthy elderly subjects. Med Sci Sports Exerc 2003;35: McHorney CA, Ware JE, Raczek AE. The MOS 36-Item Short- Form Health Survey (SF-36). II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care 1993;31: Irrgang JJ, Snyder-Mackler L, Wainner RS, Fu FH, Harner CD. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am 1998;80: Kosinski M, Keller SD, Hatoum HT, Kong SX, Ware JE Jr. The SF-36 Health Survey as a generic outcome measure in clinical trials of patients with osteoarthritis and rheumatoid arthritis: tests of data quality, scaling assumptions and score reliability. Med Care 1999;37:MS Reese NB, Bandy WD. Joint range of motion and muscle length testing. Philadelphia: WB Saunders; Cibere J, Bellamy N, Thorne A, Esdaile JM, McGorm KJ, Chalmers A, et al. Reliability of the knee examination in osteoarthritis: effect of standardization. Arthritis Rheum 2004;50: Hollis S, Campbell F. What is meant by intention to treat analysis? Survey of published randomised controlled trials. BMJ 1999;319: Portney LG, Watkins MP. Foundations for clinical research: applications to practice. 2nd ed. Upper Saddle River (NJ): Prentice Hall Health; Olejnik S, Li J, Huberty CJ, Supattathum S. Multiple testing and statistical power with modified Bonferroni procedures. J Educ Behav Stat 1997;22: Berth A, Urbach D, Awiszus F. Improvement of voluntary quadriceps muscle activation after total knee arthroplasty. Arch Phys Med Rehabil 2002;83: Mizner RL, Stevens JE, Snyder-Mackler L. Voluntary activation and decreased force production of the quadriceps femoris muscle after total knee arthroplasty. Phys Ther 2003;84: Kramer JF, Speechley M, Bourne RB, Rorabeck CH, Vaz M. Comparison of clinic- and home-based rehabilitation programs after total knee arthroplasty. Clin Orthop Relat Res 2003;410: Moffet H, Collet JP, Shapiro SH, Paradis G, Marquis F, Roy L. Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: a singleblind randomized controlled trial. Arch Phys Med Rehabil 2004;85: Steffen TM, Hacker TA, Mollinger L. Age- and gender-related test performance in community-dwelling elderly people: Six- Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Phys Ther 2002;82: Walsh M, Kennedy D, Stratford PW, Woodhouse LJ. Perioperative functional performance of women and men following total knee arthroplasty. Physiother Can 2001;53: Mizner RL, Petterson SC, Stevens JE, Vandenborne K, Snyder- Mackler L. Early quadriceps strength loss after total knee arthroplasty: the contributions of muscle atrophy and failure of voluntary muscle activation. J Bone Joint Surg Am 2005; 87: Hurley M, Newham D. The influence of arthrogenous muscle inhibition on quadriceps rehabilitation of patients with early, unilateral osteoarthritic knees. Br J Rheumatol 1993;32: Kumar PJ, McPherson EJ, Dorr LD, Wan Z, Baldwin K. Rehabilitation after total knee arthroplasty: a comparison of 2 rehabilitation techniques. Clin Orthop Relat Res 1996;331: Rajan RA, Pack Y, Jackson H, Gillies C, Asirvatham R. No need for outpatient physiotherapy following total knee arthroplasty: a randomized trial of 120 patients. Acta Orthop Scand 2004;75: Ranawat CS, Ranawat AS, Mehta A. Total knee arthroplasty rehabilitation protocol. J Arthroplasty 2003;18: Stratford PW, Kennedy D, Pagura SM, Gollish JD. The relationship between self-report and performance-related measures: questioning the content validity of timed tests. Arthritis Rheum 2003;49: Enright PL, Sherrill DL. Reference equations for the sixminute walk in healthy adults. Am J Respir Crit Care Med 1998;158:

adj., departing from the norm, not concentric, utilizing negative resistance for better client outcomes

adj., departing from the norm, not concentric, utilizing negative resistance for better client outcomes Why Eccentrics? What is it? Eccentric adj., departing from the norm, not concentric, utilizing negative resistance for better client outcomes Eccentrics is a type of muscle contraction that occurs as the

More information

Dana L. Judd, PT, DPT

Dana L. Judd, PT, DPT CURRICULUM VITAE Dana L. Judd, PT, DPT University of Colorado Physical Therapy Program Muscle Performance Laboratory 13121 E 17 th Ave, Mail Stop C244 80045 303-724-9590 (w) 303-724-2444 (f) Dana.Judd@ucdenver.edu

More information

Is 1-to-1 therapy superior to group- or home-based programs after TKA? A randomised trial.

Is 1-to-1 therapy superior to group- or home-based programs after TKA? A randomised trial. Is 1-to-1 therapy superior to group- or home-based programs after TKA? A randomised trial. Victoria Ko BAppSc (Phty) Justine Naylor PhD Ian Harris PhD Jack Crosbie PhD Anthony Yeo PhD Rajat Mittal MBBS

More information

ACL Rehabilitation Pathway. Expediating Safe Return to Optimum Performance. www.sportssurgeryclinic.com

ACL Rehabilitation Pathway. Expediating Safe Return to Optimum Performance. www.sportssurgeryclinic.com Specialists in Joint Replacement, Spinal Surgery, Orthopaedics and Sport Injuries ACL Rehabilitation Pathway Expediating Safe Return to Optimum Performance www.sportssurgeryclinic.com Contents Introduction...

More information

Total knee arthroplasty (TKA) is a commonly performed surgical

Total knee arthroplasty (TKA) is a commonly performed surgical WHITNEY MEIER, DPT, OCS 1 PhD, MPT 2 PT, PhD, OCS 3 PT, PhD, ATC 3 MD 4 PT, PhD, CHT 5 Total Knee Arthroplasty: Muscle Impairments, Functional Limitations, and Recommended Rehabilitation Approaches Total

More information

Enhanced recovery programme after TKA through multi-disciplinary collaboration

Enhanced recovery programme after TKA through multi-disciplinary collaboration Enhanced recovery programme after TKA through multi-disciplinary collaboration ChanPK(1), ChiuKY(1), FungYK(6), YeungSS(7), NgT(8), ChanMT(5), LamR(4), WongNY(3), ChoiYY(3), ChanCW(2), NgFY(1), YanCH(1)

More information

Mary LaBarre, PT, DPT,ATRIC

Mary LaBarre, PT, DPT,ATRIC Aquatic Therapy and the ACL Current Concepts on Prevention and Rehab Mary LaBarre, PT, DPT,ATRIC Anterior Cruciate Ligament (ACL) tears are a common knee injury in athletic rehab. Each year, approximately

More information

Baur C.*, Mathieu N.***, Delamorclaz S.*, Hilfiker R.***, Siegrist O.**, Blatter S**., Fournier S.*

Baur C.*, Mathieu N.***, Delamorclaz S.*, Hilfiker R.***, Siegrist O.**, Blatter S**., Fournier S.* Anterior cruciate ligament reconstruction : Comparison of Hamstring Tendon autograf vs Bone Patellar Tendon Bone autograf : a retrospective cohort study of 111 patients. Baur C.*, Mathieu N.***, Delamorclaz

More information

William J. Robertson, MD UT Southwestern Orthopedics 1801 Inwood Rd. Dallas, TX 75390-8882 Office: (214) 645-3300 Fax: (214) 3301 billrobertsonmd.

William J. Robertson, MD UT Southwestern Orthopedics 1801 Inwood Rd. Dallas, TX 75390-8882 Office: (214) 645-3300 Fax: (214) 3301 billrobertsonmd. Anterior Cruciate Ligament Reconstruction Postoperative Rehab Protocol You will follow-up with Dr. Robertson 10-14 days after surgery. At this office visit you will also see one of his physical therapists.

More information

Comparing Conventional Physical Therapy Rehabilitation With Neuromuscular Electrical Stimulation After TKA

Comparing Conventional Physical Therapy Rehabilitation With Neuromuscular Electrical Stimulation After TKA TKA Comparing Conventional Physical Therapy Rehabilitation With Neuromuscular Electrical Stimulation After TKA Michael Levine, MD; Karen McElroy, MPT; Valerie Stakich, MPT; Jodie Cicco, DPT abstract Full

More information

Evidence Review. Topic: Same-day Mobilization following Total Hip and Total Knee Arthroplasty

Evidence Review. Topic: Same-day Mobilization following Total Hip and Total Knee Arthroplasty Evidence Review Revised October 01, 2009 Topic: Same-day Mobilization following Total Hip and Total Knee Arthroplasty Background Hip and knee arthroplasty patients routinely receive postoperative physiotherapy

More information

Preoperative Health Status of Patients With Four Knee Conditions Treated With Arthroscopy

Preoperative Health Status of Patients With Four Knee Conditions Treated With Arthroscopy CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 395 pp. 164 173 2002 Lippincott Williams & Wilkins, Inc. Preoperative Health Status of Patients With Four Knee Conditions Treated With Arthroscopy Daniel

More information

Rehabilitation after ACL Reconstruction: From the OR to the Playing Field. Mark V. Paterno PT, PhD, MBA, SCS, ATC

Rehabilitation after ACL Reconstruction: From the OR to the Playing Field. Mark V. Paterno PT, PhD, MBA, SCS, ATC Objectives Rehabilitation after ACL Reconstruction: From the OR to the Playing Field Mark V. Paterno PT, PhD, MBA, SCS, ATC Coordinator of Orthopaedic and Sports Physical Therapy Cincinnati Children s

More information

Neuromuscular electrical

Neuromuscular electrical A Modified Neuromuscular Electrical Stimulation Protocol for Quadriceps Strength Training Following Anterior Cruciate Ligament Reconstruction G. Kelley Fitzgerald, PT, PhD, OCS 1 Sara R. Piva, PT, MS,

More information

What factors determine poor functional outcome following Total Knee Replacement (TKR)?

What factors determine poor functional outcome following Total Knee Replacement (TKR)? Specific Question: What factors determine poor functional outcome following Total Knee Replacement ()? Clinical bottom line All groups derived benefit from undergoing a, reviews suggests that the decision

More information

Knee Pain/OA Physical Therapy Approaches

Knee Pain/OA Physical Therapy Approaches Knee Pain/OA Physical Therapy Approaches G. Kelley Fitzgerald, PT, PhD, FAPTA Professor, Department of Physical Therapy, School of Health and Rehabilitation Sciences Director, Physical Therapy Clinical

More information

Rehabilitation guidelines for patients undergoing knee arthroscopy

Rehabilitation guidelines for patients undergoing knee arthroscopy Rehabilitation guidelines for patients undergoing knee arthroscopy At the RNOH, our emphasis is patient specific, which encourages recognition of those who may progress slower then others. We also want

More information

The Role of Acupuncture with Electrostimulation in the Prozen Shoulder

The Role of Acupuncture with Electrostimulation in the Prozen Shoulder The Role of Acupuncture with Electrostimulation in the Prozen Shoulder Yu-Te Lee A. Aim To evaluate the efficacy of acupuncture with electrostimulation in conjunction with physical therapy in improving

More information

Draft South West LHIN Hip and Knee Replacement Program Post Acute Stream Algorithm - Guidelines and Milestones

Draft South West LHIN Hip and Knee Replacement Program Post Acute Stream Algorithm - Guidelines and Milestones Post Acute Stream Guidelines for patients to attend Post-Acute Stream Stream Overview 1)Discharge home to Outpatient Rehab (hospital funded or Private clinic). RAPT score >9 (only assessed pre-operatively)or?

More information

SUMMARY This PhD thesis addresses the long term recovery of hemiplegic gait in severely affected stroke patients. It first reviews current rehabilitation research developments in functional recovery after

More information

A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course

A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course 2014 Annual Breast Cancer Rehabilitation Healthcare Provider Event A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course November 7 th and 8 th, 2014 Mercer University, Atlanta,

More information

TENS, Electroacupuncture and Ice Massage: Comparison of Treatment for Osteoarthritis of the Knee

TENS, Electroacupuncture and Ice Massage: Comparison of Treatment for Osteoarthritis of the Knee TENS, Electroacupuncture and Ice Massage: Comparison of Treatment for Osteoarthritis of the Knee Merih Yurtkuran, Tuncer Kocagil Uludag University Medical Faculty Department of Physical Therapy and Rehabilitation,

More information

Rapid Mobilization Decreases Length-of-Stay in Joint Replacement Patients

Rapid Mobilization Decreases Length-of-Stay in Joint Replacement Patients 222 Rapid Mobilization Decreases Length-of-Stay in Joint Replacement Patients Gregory Tayrose, M.D., Debbie Newman, B.S., James Slover, M.D., M.S., Fredrick Jaffe, M.D., Tracey Hunter, B.S., and Joseph

More information

Prepared by: Kaitlin MacDonald, MOT, OTR/L 1, Stephanie Ramey, MS, OTR/L 1, Rebecca Martin, OTR/L, OTD 1 and Glendaliz Bosques 1,2, MD

Prepared by: Kaitlin MacDonald, MOT, OTR/L 1, Stephanie Ramey, MS, OTR/L 1, Rebecca Martin, OTR/L, OTD 1 and Glendaliz Bosques 1,2, MD 1 The Relationship between Power and Manual Wheelchair Mobility and Upper Extremity Pain in Youths with Low Level Cervical Spinal Cord Injury Prepared by: Kaitlin MacDonald, MOT, OTR/L 1, Stephanie Ramey,

More information

Anterior Cruciate Ligament (ACL) Rehabilitation

Anterior Cruciate Ligament (ACL) Rehabilitation Thomas D. Rosenberg, M.D. Vernon J. Cooley, M.D. Charles C. Lind, M.D. Anterior Cruciate Ligament (ACL) Rehabilitation Dear Enclosed you will find a copy of our Anterior Cruciate Ligament (ACL) Rehabilitation

More information

A User's Guide to: Rheumatoid and Arthritis Outcome Score RAOS

A User's Guide to: Rheumatoid and Arthritis Outcome Score RAOS RAOS User's Guide 2004 A User's Guide to: Rheumatoid and Arthritis Outcome Score RAOS RAOS is developed as an instrument to assess the patients opinion about their hips/knees and/or feet and associated

More information

Rehabilitation Protocol: Total Knee Arthroplasty (TKA)

Rehabilitation Protocol: Total Knee Arthroplasty (TKA) Rehabilitation Protocol: Total Knee Arthroplasty (TKA) Department of Orthopaedic Surgery Lahey Hospital & Medical Center, Burlington 781-744-8650 Lahey Outpatient Center, Lexington 781-372-7020 Lahey Medical

More information

Landing Biomechanics Utilizing Different Tasks: Implications in ACL Injury Research. Adam Hernandez Erik Swartz, PhD ATC Dain LaRoche, PhD

Landing Biomechanics Utilizing Different Tasks: Implications in ACL Injury Research. Adam Hernandez Erik Swartz, PhD ATC Dain LaRoche, PhD A Gender Comparison of Lower Extremity Landing Biomechanics Utilizing Different Tasks: Implications in ACL Injury Research Adam Hernandez Erik Swartz, PhD ATC Dain LaRoche, PhD Anterior Cruciate Ligament

More information

1/12/2015. Tom Ambury, PT, CHC

1/12/2015. Tom Ambury, PT, CHC Tom Ambury, PT, CHC Attendees will understand the key components of the initial evaluation Attendees will understand the importance of the initial evaluation in establishing the skilled need for therapy

More information

POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION POSTOPERATIVE REHABILITATION PROTOCOL

POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION POSTOPERATIVE REHABILITATION PROTOCOL Corey A. Wulf, MD POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION POSTOPERATIVE REHABILITATION PROTOCOL The range of motion allowed after posterior cruciate ligament reconstructive surgery is dependent upon

More information

Health Care Subsidy and Outcomes of Total Knee Arthroplasty in Asians

Health Care Subsidy and Outcomes of Total Knee Arthroplasty in Asians Health Care Subsidy and Outcomes of Total Knee Arthroplasty in Asians Hamid Rahmatullah bin Abd Razak, MBBS, MRCS(Glasg); Toh Rui Xiang, MBBS; Chong Hwei Chi, BSc; Tan Hwee Chye Andrew, MBBS, FRCS(Orth)

More information

Total Knee Replacement Specifications 2014 (01/01/2012 to 12/31/2012 Dates of Procedure)

Total Knee Replacement Specifications 2014 (01/01/2012 to 12/31/2012 Dates of Procedure) Summary of Changes Removed following ICD-9 Procedure s: 81.54 Total Knee Replacement (Bicompartmental, Partial Knee Replacement, Tricompartmental, Unicompartmental (hemijoint)). 81.55 Revision of Knee

More information

Rehabilitation Protocol: Total Hip Arthroplasty (THA)

Rehabilitation Protocol: Total Hip Arthroplasty (THA) Rehabilitation Protocol: Total Hip Arthroplasty (THA) Department of Orthopaedic Surgery Lahey Hospital & Medical Center, Burlington 781-744-8650 Lahey Outpatient Center, Lexington 781-372-7020 Lahey Medical

More information

Theodore B. Shybut, M.D. 7200 Cambridge St. #10A Houston, Texas 77030 Phone: 713-986-5590 Fax: 713-986-5521. Sports Medicine

Theodore B. Shybut, M.D. 7200 Cambridge St. #10A Houston, Texas 77030 Phone: 713-986-5590 Fax: 713-986-5521. Sports Medicine Anterior Cruciate Ligament Reconstruction Accelerated Rehab This rehabilitation protocol has been designed for patients with ACL reconstruction who anticipate returning to a high level of activity as quickly

More information

A Large, Randomized, Prospective Study of the Impact of a Pre-Run Stretch on the Risk of Injury in Teenage and Older Runners

A Large, Randomized, Prospective Study of the Impact of a Pre-Run Stretch on the Risk of Injury in Teenage and Older Runners A Large, Randomized, Prospective Study of the Impact of a Pre-Run Stretch on the Risk of Injury in Teenage and Older Runners Daniel Pereles 1, MD, Alan Roth 2 PhD, Darby JS Thompson 3 MS 1 CAQ Sports Medicine,

More information

MN Community Measurement Total Knee Replacement Impact and Recommendation Document June 2010

MN Community Measurement Total Knee Replacement Impact and Recommendation Document June 2010 MN Community Measurement Total Knee Replacement Impact and Recommendation Document June 2010 Degree of Impact Relevance to Consumers, Employers and Payers Annually there are over 500,000 total knee replacement

More information

The Insall Scott Kelly Center for Orthopaedics and Sports Medicine 210 East 64th Street, 4 th Floor, New York, NY 10065

The Insall Scott Kelly Center for Orthopaedics and Sports Medicine 210 East 64th Street, 4 th Floor, New York, NY 10065 ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION POST-OPERATIVE REHABILITATION PROTOCOL 2003 AUTOGRAFT BONE-PATELLA TENDON-BONE and ALLOGRAFT PROTOCOL PHASE I-EARLY FUNCTIONAL (WEEKS 1-2) Goals: 1. Educate re:

More information

Transmittal 55 Date: MAY 5, 2006. SUBJECT: Changes Conforming to CR3648 for Therapy Services

Transmittal 55 Date: MAY 5, 2006. SUBJECT: Changes Conforming to CR3648 for Therapy Services CMS Manual System Pub 100-03 Medicare National Coverage Determinations Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 55 Date: MAY 5, 2006 Change

More information

Standard of Care: Inpatient Intervention for Total Hip Arthroplasty ICD-9 (719.7, 719.1)

Standard of Care: Inpatient Intervention for Total Hip Arthroplasty ICD-9 (719.7, 719.1) Department of Rehabilitation Services Occupational Therapy Standard of Care: Inpatient Intervention for Total Hip Arthroplasty ICD-9 (719.7, 719.1) Case Type / Diagnosis: This Standard of Care applies

More information

Rationale of The Knee Society Clinical Rating System. John N. Insall, MD, Lawrence D. Dorr, MD, Richard D. Scott, MD, and W.

Rationale of The Knee Society Clinical Rating System. John N. Insall, MD, Lawrence D. Dorr, MD, Richard D. Scott, MD, and W. Rationale of The Knee Society Clinical Rating System John N. Insall, MD, Lawrence D. Dorr, MD, Richard D. Scott, MD, and W. Norman Scott, MD From the Hospital for Special Surgery, affiliated with The New

More information

How To Test For Muscle Strength

How To Test For Muscle Strength Myositis Core Set Measures of Activity, including MMT8, and the Preliminary Definitions of Improvement Lisa G. Rider, M.D. EAG, National Institute of Environmental Health Sciences, NIH, DHHS Bethesda,

More information

Outpatient Physical Therapy Locations

Outpatient Physical Therapy Locations Outpatient Physical Therapy Locations Physical Therapy at Clinton Health Campus 908-735-3930 1783 Route 31N, Suite 103 Clinton, NJ Hunterdon Sports and Physical Therapy 908-237-7096 222 Route 31N Flemington,

More information

ACL Reconstruction: Patellar Tendon Graft/Hamstring Tendon Graft

ACL Reconstruction: Patellar Tendon Graft/Hamstring Tendon Graft ACL Reconstruction: Patellar Tendon Graft/Hamstring Tendon Graft Patellar Tendon Graft/Hamstring Tendon Graft General Information: The intent of these guidelines is to provide the therapist with direction

More information

Hip Rehab: Things to Consider. Sue Torrence, MS, PT, ATC Lead Physical Therapist

Hip Rehab: Things to Consider. Sue Torrence, MS, PT, ATC Lead Physical Therapist Hip Rehab: Things to Consider Sue Torrence, MS, PT, ATC Lead Physical Therapist Where to Start? Objectives: Discuss injuries related to hip dysfunction Review commonly used functional tests for posteriolateral

More information

Exercise therapy in the management of upper limb dysfunction in people with Rheumatoid Arthritis. Speaker declaration: no conflicts of interest

Exercise therapy in the management of upper limb dysfunction in people with Rheumatoid Arthritis. Speaker declaration: no conflicts of interest Exercise therapy in the management of upper limb dysfunction in people with Rheumatoid Arthritis Speaker declaration: no conflicts of interest Exercise a planned, structured and repetitive bodily movement

More information

ACCELERATED REHABILITATION PROTOCOL FOR POST OPERATIVE POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION DR LEO PINCZEWSKI DR JUSTIN ROE

ACCELERATED REHABILITATION PROTOCOL FOR POST OPERATIVE POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION DR LEO PINCZEWSKI DR JUSTIN ROE ACCELERATED REHABILITATION PROTOCOL FOR POST OPERATIVE POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION DR LEO PINCZEWSKI DR JUSTIN ROE January 2005 Rationale of Accelerated Rehabilitation Rehabilitation after

More information

OPTIMAL CORE TRAINING FOR FUNCTIONAL GAINS AND PEAK PERFORMANCE: CXWORX

OPTIMAL CORE TRAINING FOR FUNCTIONAL GAINS AND PEAK PERFORMANCE: CXWORX OPTIMAL CORE TRAINING FOR FUNCTIONAL GAINS AND PEAK PERFORMANCE: CXWORX Jinger S. Gottschall 1, Jackie Mills 2, and Bryce Hastings 2 1 The Pennsylvania State University, University Park, USA 2 Les Mills

More information

Audit on treatment and recovery of ankle sprain

Audit on treatment and recovery of ankle sprain Hong Kong Journal of Emergency Medicine Audit on treatment and recovery of ankle sprain WY Lee Study Objectives: The object of this study is to audit the care of ankle sprain of different severity and

More information

Handicap after acute whiplash injury A 1-year prospective study of risk factors

Handicap after acute whiplash injury A 1-year prospective study of risk factors 1 Handicap after acute whiplash injury A 1-year prospective study of risk factors Neurology 2001;56:1637-1643 (June 26, 2001) Helge Kasch, MD, PhD; Flemming W Bach, MD, PhD; Troels S Jensen, MD, PhD From

More information

234 Full-Text Publication Productivity in. 246 Head-Shake Sensory Organization Test. 254 Use of Presenteeism Scales in Chronic

234 Full-Text Publication Productivity in. 246 Head-Shake Sensory Organization Test. 254 Use of Presenteeism Scales in Chronic February 2011 Volume 91 Number 2 ProfessionWatch 165 The Revised Research Agenda for Physical Therapy Research Reports 178 Passive Mobilization of Shoulder Joints 190 Comprehensive Databases for Physical

More information

Noyes Knee Institute Rehabilitation Protocol for Primary ACL Reconstruction: Early Return to Strenuous Activities

Noyes Knee Institute Rehabilitation Protocol for Primary ACL Reconstruction: Early Return to Strenuous Activities Noyes Knee Institute Rehabilitation Protocol for Primary ACL Reconstruction: Early Return to Strenuous Activities 1-2 3-4 5-6 7-8 9-12 4 5 6 7-12 Brace: immobilizer for patient comfort () minimum goals:

More information

Predictors of Physical Therapy Use in Patients with Rheumatoid Arthritis

Predictors of Physical Therapy Use in Patients with Rheumatoid Arthritis Predictors of Physical Therapy Use in Patients with Rheumatoid Arthritis Maura Iversen,, PT, DPT, SD, MPH 1,2,3 Ritu Chhabriya,, MSPT 4 Nancy Shadick, MD 2,3 1 Department of Physical Therapy, Northeastern

More information

The Influence of Functional Electrical Stimulation (FES) Cycling on Spasticity in Adolescents with Spinal Cord Injury

The Influence of Functional Electrical Stimulation (FES) Cycling on Spasticity in Adolescents with Spinal Cord Injury 1 The Influence of Functional Electrical Stimulation (FES) Cycling on Spasticity in Adolescents with Spinal Cord Injury Prepared by:rebecca Martin, OTR/L, OTD 1, Meredith Bourque, PT, DPT 1, Glendaliz

More information

Physical Therapy Sample Reports 2009

Physical Therapy Sample Reports 2009 Sample Reports 2009 Includes: Progress/ Treatment Note Plan of Care from Initial Evaluation Initial Evaluation/ Examination (full-length compliant) Ten (10) Visit Progress Report Discharge Summary Physician

More information

Anterior Cruciate Ligament Reconstruction. ACL Rehab Protocol

Anterior Cruciate Ligament Reconstruction. ACL Rehab Protocol Anterior Cruciate Ligament Reconstruction Rehab Protocol This rehabilitation protocol has been designed for patients following ACL reconstruction who anticipate returning to a high level of activity as

More information

The Use of the Lokomat System in Clinical Research

The Use of the Lokomat System in Clinical Research International Neurorehabilitation Symposium February 12, 2009 The Use of the Lokomat System in Clinical Research Keith Tansey, MD, PhD Director, Spinal Cord Injury Research Crawford Research Institute,

More information

Post Operative Total Knee Replacement Protocol Brian White, MD www.western-ortho.com

Post Operative Total Knee Replacement Protocol Brian White, MD www.western-ortho.com Post Operative Total Knee Replacement Protocol Brian White, MD www.western-ortho.com The intent of this protocol is to provide guidelines for progression of rehabilitation. It is not intended to serve

More information

Neck Pain & Cervicogenic Headache Integrating Research into Practice: San Luis Sports Therapy s Approach to Evidence-Based Practice

Neck Pain & Cervicogenic Headache Integrating Research into Practice: San Luis Sports Therapy s Approach to Evidence-Based Practice Neck Pain & Cervicogenic Headache Integrating Research into Practice: San Luis Sports Therapy s Approach to Evidence-Based Practice PROBLEM: Neck Pain and Cervicogenic Headache 66% Proportion of individuals

More information

Rehabilitation Guidelines for Patellar Tendon and Quadriceps Tendon Repair

Rehabilitation Guidelines for Patellar Tendon and Quadriceps Tendon Repair UW Health Sports Rehabilitation Rehabilitation Guidelines for Patellar Tendon and Quadriceps Tendon Repair The knee consists of four bones that form three joints. The femur is the large bone in the thigh

More information

William J. Robertson, MD UT Southwestern Orthopedics 1801 Inwood Rd. Dallas, TX 75390-8882 Office: (214) 645-3300 Fax: (214) 3301 billrobertsonmd.

William J. Robertson, MD UT Southwestern Orthopedics 1801 Inwood Rd. Dallas, TX 75390-8882 Office: (214) 645-3300 Fax: (214) 3301 billrobertsonmd. Arthroscopic Rotator Cuff Repair Postoperative Rehab Protocol Starting the first day after surgery you should remove the sling 3-4 times per day to perform pendulum exercises and elbow/wrist range of motion

More information

Progression to the next phase is based on Clinical Criteria and/or Time Frames as appropriate.

Progression to the next phase is based on Clinical Criteria and/or Time Frames as appropriate. BRIGHAM AND WOMEN S HOSPITAL Department of Rehabilitation Services Phyp Physical Therapy Total Hip Arthroplasty/ Hemiarthroplasty Protocol: The intent of this protocol is to provide the clinician with

More information

For Technical Assistance with HCUP Products: Email: hcup@ahrq.gov. Phone: 1-866-290-HCUP

For Technical Assistance with HCUP Products: Email: hcup@ahrq.gov. Phone: 1-866-290-HCUP HCUP Projections 2003 to 2012 Report # 2012-03 Contact Information: Healthcare Cost and Utilization Project (HCUP) Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20850 http://www.hcup-us.ahrq.gov

More information

Dr. Khaled E. Ayad Alrehab City, Cairo Egypt Cell phone: 002 0100 617 3954 khaled-ayad@hotmail.com

Dr. Khaled E. Ayad Alrehab City, Cairo Egypt Cell phone: 002 0100 617 3954 khaled-ayad@hotmail.com Dr. Khaled E. Ayad Alrehab City, Cairo Egypt Cell phone: 002 0100 617 3954 khaled-ayad@hotmail.com Education Doctor of Philosophy (physical therapy) Cairo University Cairo, Egypt, Jan 2006 Title of Ph.D.

More information

Gait with Assistive Devices

Gait with Assistive Devices Gait with Assistive Devices Review Last Lecture Weak dorsiflexors? Vaulting? Hip hiking? Weak hip abductors? Hip circumduction? Ataxic gait? Antalgic gait? Explain the line of gravity Ambulation with Assistive

More information

Worsening thigh pain after blunt trauma

Worsening thigh pain after blunt trauma Images in Radiology Worsening thigh pain after blunt trauma LT Kendall Lane MD MC USN A 19 year-old otherwise healthy male presented with right thigh pain for three weeks after another player s knee struck

More information

Health Literacy Screening Tools

Health Literacy Screening Tools Health Literacy Screening Tools Rapid Estimate of Adult Literacy in Medicine (REALM) Description A 66-item health-related word recognition test arranged in order of increasing difficulty. Provides a reading

More information

FACTORS ASSOCIATED WITH ADVERSE EVENTS IN MAJOR ELECTIVE SPINE, KNEE, AND HIP INPATIENT ORTHOPAEDIC SURGERY

FACTORS ASSOCIATED WITH ADVERSE EVENTS IN MAJOR ELECTIVE SPINE, KNEE, AND HIP INPATIENT ORTHOPAEDIC SURGERY FACTORS ASSOCIATED WITH ADVERSE EVENTS IN MAJOR ELECTIVE SPINE, KNEE, AND HIP INPATIENT ORTHOPAEDIC SURGERY Dov B. Millstone, Anthony V. Perruccio, Elizabeth M. Badley, Y. Raja Rampersaud Dalla Lana School

More information

Case Series on Chronic Whiplash Related Neck Pain Treated with Intraarticular Zygapophysial Joint Regeneration Injection Therapy

Case Series on Chronic Whiplash Related Neck Pain Treated with Intraarticular Zygapophysial Joint Regeneration Injection Therapy Pain Physician 2007; 10:313-318 ISSN 1533-3159 Case Series Case Series on Chronic Whiplash Related Neck Pain Treated with Intraarticular Zygapophysial Joint Regeneration Injection Therapy R. Allen Hooper

More information

Patient / Carer Empowerment in Rehabilitation: Challenges and Success Factors

Patient / Carer Empowerment in Rehabilitation: Challenges and Success Factors 東 華 三 院 黃 大 仙 醫 院 Tung Wah Group of Hospitals Wong Tai Sin Hospital Patient / Carer Empowerment in Rehabilitation: Challenges and Success Factors HA Convention 2015 Li KY, Tang IFK, Kwong MWY, Chan RWH,

More information

RNOH Physiotherapy Department (020 8909 5820) Rehabilitation guidelines for patients undergoing spinal surgery

RNOH Physiotherapy Department (020 8909 5820) Rehabilitation guidelines for patients undergoing spinal surgery RNOH Physiotherapy Department (020 8909 5820) Rehabilitation guidelines for patients undergoing spinal surgery As a specialist orthopaedic hospital we recognise that our broad and often complex patient

More information

Clinical Movement Analysis to Identify Muscle Imbalances and Guide Exercise

Clinical Movement Analysis to Identify Muscle Imbalances and Guide Exercise CLINICAL EVALUATION & TESTING Darin A. Padua, PhD, ATC, Column Editor Clinical Movement Analysis to Identify Muscle Imbalances and Guide Exercise Christopher J. Hirth, MS, ATC, PT, PES University of rth

More information

Ulnar Collateral Ligament Reconstruction Tommy John Surgery. Neal McIvor, Alyssa Pfanner, Caleb Sato

Ulnar Collateral Ligament Reconstruction Tommy John Surgery. Neal McIvor, Alyssa Pfanner, Caleb Sato Ulnar Collateral Ligament Reconstruction Tommy John Surgery By Neal McIvor, Alyssa Pfanner, Caleb Sato Case Study 21 y.o. Male Collegiate Baseball Pitcher Right elbow preoperatively diagnosed: UCL rupture

More information

Virtual Reality Technology in Stroke Rehabilitation: Ready for Prime Time

Virtual Reality Technology in Stroke Rehabilitation: Ready for Prime Time Virtual Reality Technology in Stroke Rehabilitation: Ready for Prime Time Hillel Finestone, MD CM, FRCPC (Physiatrist/PM&R) Ontario Hospital Association Third Annual Senior Friendly Hospital Care Conference

More information

Spinal cord injury hospitalisation in a rehabilitation hospital in Japan

Spinal cord injury hospitalisation in a rehabilitation hospital in Japan 1994 International Medical Society of Paraplegia Spinal cord injury hospitalisation in a rehabilitation hospital in Japan Y Hasegawa MSW, l M Ohashi MD, l * N Ando MD, l T. Hayashi MD, l T Ishidoh MD,

More information

Impact of adhesive capsulitis on quality of life in elderly subjects with diabetes: A cross sectional study

Impact of adhesive capsulitis on quality of life in elderly subjects with diabetes: A cross sectional study Original Article Impact of adhesive capsulitis on quality of life in elderly subjects with diabetes: A cross sectional study Saumen Gupta, Kavitha Raja, Manikandan N Department of Physical Therapy, Manipal

More information

Basic gait parameters : Reference data for normal subjects, 10-79 years of age

Basic gait parameters : Reference data for normal subjects, 10-79 years of age Journal of Rehabilitation Research and Development Vol. 30 No. 2 1993 Pages 210 223 'V"Ze Department of Veterans Affairs A Technical Note Basic gait parameters : Reference data for normal subjects, 10-79

More information

What is Osteoarthritis? Who gets Osteoarthritis? What can I do when I am diagnosed with Osteoarthritis? What can my doctor do to help me?

What is Osteoarthritis? Who gets Osteoarthritis? What can I do when I am diagnosed with Osteoarthritis? What can my doctor do to help me? Knee Osteoarthritis What is Osteoarthritis? Osteoarthritis is a disease process that affects the cartilage within a joint. Cartilage exists at the surface of the ends of the bones and provides joints with

More information

world-class orthopedic care right in your own backyard.

world-class orthopedic care right in your own backyard. world-class orthopedic care right in your own backyard. Patient Promise: At Adventist Hinsdale Hospital, our Patient Promise means we strive for continued excellence in everything we do. This means you

More information

FEMORAL NECK FRACTURE FOLLOWING TOTAL KNEE REPLACEMENT

FEMORAL NECK FRACTURE FOLLOWING TOTAL KNEE REPLACEMENT 1 FEMORAL NECK FRACTURE FOLLOWING TOTAL KNEE REPLACEMENT László Sólyom ( ), András Vajda & József Lakatos Orthopaedic Department, Semmelweis University, Medical Faculty, Budapest, Hungary Correspondence:

More information

Anterior Cruciate Ligament Reconstruction Rehabilitation Protocol

Anterior Cruciate Ligament Reconstruction Rehabilitation Protocol Anterior Cruciate Ligament Reconstruction Rehabilitation Protocol GENERAL CONSIDERATIONS * This handout serves as a general outline for you as a patient to better understand guidelines and time frames

More information

Plantar fascia. Plantar Fasciitis (pain in the heel of the foot)

Plantar fascia. Plantar Fasciitis (pain in the heel of the foot) ! Plantar fascia Plantar Fasciitis (pain in the heel of the foot) Plantar Fasciitis is the most common foot problem seen in runners and is often associated with an increase in running mileage. Typically

More information

Cincinnati Sportsmedicine and Orthopaedic Center

Cincinnati Sportsmedicine and Orthopaedic Center Cincinnati Sportsmedicine and Orthopaedic Center Total Knee Replacement: Rehabilitation Protocol This rehabilitation protocol was developed for patients who have had a cemented total knee arthroplasty.

More information

Exercise Improves Early Functional Recovery After Total Hip Arthroplasty

Exercise Improves Early Functional Recovery After Total Hip Arthroplasty CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 408, pp. 193 200 2003 Lippincott Williams & Wilkins, Inc. Exercise Improves Early Functional Recovery After Total Hip Arthroplasty Helen J. Gilbey, PhD*;

More information

Study Design and Statistical Analysis

Study Design and Statistical Analysis Study Design and Statistical Analysis Anny H Xiang, PhD Department of Preventive Medicine University of Southern California Outline Designing Clinical Research Studies Statistical Data Analysis Designing

More information

Bayada Home Health. Health Policy. Objectives. Quality. Quality Defined. Health Defined 11/24/2009. Institutes of Medicine (IOM)

Bayada Home Health. Health Policy. Objectives. Quality. Quality Defined. Health Defined 11/24/2009. Institutes of Medicine (IOM) Engaging the Professional Workforce Mike Johnson, PT, PhD, OCS Director of Clinical Leadership Visit Clinical Leadership (VCL) Office Skilled Visit Services; Bayada Nurses Moorestown, New Jersey Creating

More information

Hip precautions following total hip replacement: to implement or not implement?

Hip precautions following total hip replacement: to implement or not implement? Hip precautions following total hip replacement: to implement or not implement? Lauren Porter Senior Occupational Therapist, Abergele Hospital, Wales Jade Cope Clinical Specialist Occupational Therapist,

More information

Corporate Medical Policy Continuous Passive Motion in the Home Setting

Corporate Medical Policy Continuous Passive Motion in the Home Setting Corporate Medical Policy Continuous Passive Motion in the Home Setting File Name: Origination: Last CAP Review: Next CAP Review: Last Review: continuous_passive_motion_in_the_home_setting 9/1993 6/2016

More information

frequently asked questions Knee and Hip Joint Replacement Technology

frequently asked questions Knee and Hip Joint Replacement Technology frequently asked questions Knee and Hip Joint Replacement Technology frequently asked questions Knee and Hip Joint Replacement Technology Recently, you may have seen advertisements from legal companies

More information

Powered by SELECT MEDICAL Family of Brands. Obesity in Rehab- a Weighty Topic

Powered by SELECT MEDICAL Family of Brands. Obesity in Rehab- a Weighty Topic Powered by SELECT MEDICAL Family of Brands Obesity in Rehab- a Weighty Topic Obesity Trends* Among U.S. Adults BRFSS, 1985 No Data

More information

total hip replacement

total hip replacement total hip replacement EXCERCISE BOOKLET patient s name: date of surgery: physical therapist: www.jointpain.md Get Up and Go Joint Program Philosophy: With the development of newer and more sophisticated

More information

MAKOplasty MAKOplasty MAKOplasty MAKOplasty MAKOplasty MAKOplasty MAKOplasty MAKOplasty MAKOplasty

MAKOplasty MAKOplasty MAKOplasty MAKOplasty MAKOplasty MAKOplasty MAKOplasty MAKOplasty MAKOplasty Pre-op Patient Guide to Partial Knee Resurfacing Your Guide to Partial Knee Resurfacing Page I 1 Partial Knee Resurfacing...2 Benefits Possible with the Procedure...4 Your Guide to Surgery...5 Frequently

More information

8 General discussion. Chapter 8: general discussion 95

8 General discussion. Chapter 8: general discussion 95 8 General discussion The major pathologic events characterizing temporomandibular joint osteoarthritis include synovitis and internal derangements, giving rise to pain and restricted mobility of the temporomandibular

More information

W40 Total prosthetic replacement of knee joint using cement

W40 Total prosthetic replacement of knee joint using cement Bedfordshire and Hertfordshire Priorities Forum statement Number: 33 Subject: Referral criteria for patients from primary care presenting with knee pain due to ostoarthritis, and clinical threshold for

More information

GENERAL ADMISSION CRITERIA INPATIENT REHABILITATION PROGRAMS

GENERAL ADMISSION CRITERIA INPATIENT REHABILITATION PROGRAMS Originator: Case Management Original Date: 9/94 Review/Revision: 6/96, 2/98, 1/01, 4/02, 8/04, 3/06, 03/10, 3/11, 3/13 Stakeholders: Case Management, Medical Staff, Nursing, Inpatient Therapy GENERAL ADMISSION

More information

12. Physical Therapy (PT)

12. Physical Therapy (PT) 1 2. P H Y S I C A L T H E R A P Y ( P T ) 12. Physical Therapy (PT) Clinical presentation Interventions Precautions Activity guidelines Swimming Generally, physical therapy (PT) promotes health with a

More information

Anterior Cruciate Ligament Reconstruction Delayed Rehab Dr. Walter R. Lowe

Anterior Cruciate Ligament Reconstruction Delayed Rehab Dr. Walter R. Lowe Anterior Cruciate Ligament Reconstruction Delayed Rehab Dr. Walter R. Lowe This rehabilitation protocol has been designed for patients who have undergone an ACL reconstruction (HS graft/ptg/allograft)

More information

Rehabilitation. Rehabilitation. Walkers, Crutches, Canes

Rehabilitation. Rehabilitation. Walkers, Crutches, Canes Walkers, Crutches, Canes These devices provide support through your arms to limit the amount of weight on your operated hip. Initially, after a total hip replacement you will use a walker to get around.

More information

The Unhappy total knee replacement patient whose X rays look fine. Can we predict, prevent and treat. Myles RJ Coolican and Kunal Dhurve

The Unhappy total knee replacement patient whose X rays look fine. Can we predict, prevent and treat. Myles RJ Coolican and Kunal Dhurve The Unhappy total knee replacement patient whose X rays look fine Introduction: Can we predict, prevent and treat Myles RJ Coolican and Kunal Dhurve Total knee replacement (TKR) is an effective treatment

More information

Indications for Treatment: Indications for treatment include pain, swelling, instability, loss of mobility and function.

Indications for Treatment: Indications for treatment include pain, swelling, instability, loss of mobility and function. BRIGHAM AND WOMEN S HOSPITAL Department of Rehabilitation Services Physical Therapy ICD 9 Codes: 844.1 Case Type / Diagnosis: The anatomy of the medial knee has been divided into 3 layers, consisting of

More information