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

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1 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? appropriate screening tool Independent, supervision or minimal assistance with transfers if support available Independent or supervision required with basic ADLs Independent mobility on level with walker/crutches Independent or supervision with stairs, if applicable Independent or supervision with bed exercises Able to retain and apply info re: restrictions and/or WBing consistently Able to walk 50m with appropriate gait aid Details outlined in next table Should already have: Transportation for outpatient rehab visits 2)Discharge home or to Respite/Convalescent Bed with CCAC Follow-up RAPT score 6-9 (only assessed pre-operatively)or? appropriate screening tool Acute care substitution, short LOS ie. 5 days post-op or less Client is able to transfer safely in and out of bed (with available level of support) Client is able to safely ambulate with prescribed walking aids on the level (with available level of support) Pain and swelling limiting overall physical function, mobility and exercise tolerance Difficulty leaving residence to attend outpt. Client s condition would be adversely affected by traveling to receive care Unable to enter and exit home with supervision or minimal assistance Exacerbation of pre-morbid condition eg. COPD Limited activity tolerance eg. Unable to walk 50m The person s plan of care is reasonably expected to result in: Progress toward established goals in rehabilitation, or, Delay or prevention of deterioration in medical condition, or, Delay or prevention of transfer to an alternate (institutional) mode of 1 Discharged from stream when able to access outpt rehab (stream #1) or able to self manage ie. exercise on own and progress with satisfactory ambulation

2 care Occupational Therapy Minimal to moderate assistance with basic ADLs Requiring re-enforcement for joint protection strategies Requires follow-up re: equipment needs and home accessibility Home safety concerns ie. cognitive status, falls risk, etc. 3)Discharge to Facility Based Rehabilitation ie. inpt. Rehab, Respite/Convalescent Bed with facility followup, Complex continuing care, LTC (own Rehab) Nursing Care Requires frequent dressing changes 2 o to greater than normal drainage For Fragmin injections or administering of medication if limited home support or inability to perform RAPT score 6-9 or <6 (only assessed pre-operatively)or? appropriate screening tool No home support or support unable to manage with current status Assistance up to max Ax1 with transfers Assistance up to max Ax1 with ADLs Assistance up to max Ax1 with mobility Need for rehab services and/or no or limited access to rehabilitation services Unable to manage current home accessibility and environment Patient may need cueing or is unable to manage with WBing and restrictions Demonstrate rehab potential Bilateral joint replacement surgery Patients progress to stream #1 or #2 or DC Pathway to be determined by rehab facility 2

3 Discharge home with Outpatient Rehab Pathway for TKA (8-12 PT visits) Week 1 Assessment TKA patients begin outpatient rehab within 5 days of discharge Review post-operative exercises Outcome measures TUG and LEFS, NPRS, PSFS, quads lag Gait assessment and training Identify sub-group that may participate in group exercise program or continue without face to face PT visits: Primary TKA Unicompartmental knee replacement > 90 o of flexion pre-operatively (?) No hip involvement No RA Good family support Highly motivated to do own rehab Post-operative ROM 90 o flexion, extension 10 o Quads 3/5 Instructor of group exercise program should notify/contact treating physiotherapist if any of the following situations apply to the patient: Any increase in redness around the incision from the initial class Decrease in knee ROM by 5 o (extension or flexion) Change in patients mobility status from better to worse eg. Patient has been using crutches but can no longer walk with crutches safely and requires a standard walker Any adverse event such as a fall at home or in the class, change in medial status No change in patients ROM in a one week time interval if the range is < 110 o of flexion or is lacking > 7 o of extension Concerns such as shortness breath, significant change in swelling 3 Increase in patient reported pain levels by > 3 points from week to week or from initial class Any other concerns at the discretion of the individual instructing the class instructing the class Week 1-6 Treatment Objectives Continue with ROM exercises Continue management of swelling Progress strengthening and flexibility exercises as able Proprioception exercises Progression of gait to no aid or to preoperative gait aid Endurance Work simulation exercises as applicable Independent gait with crutches or cane (depends on pre-operative gaid aid needs) Knee ROM 80 o of flexion No quads lag LEFS 20 Week 6-12 Milestones, Criteria for Discharge TUG 10 secs Independent mobility ROM 110 o of flexion 5 o of Extension No quads lag Grade 4 quads strength

4 around knee or lower leg, exquisite tenderness on palpating calf muscle Discharge Home with Outpatient Rehab for THA (3-5 PT Visits) Independent with home exercise program Able to retain and apply info re: restrictions and/or WBing consistently TUG 35 secs LEFS 15 Week 2 Assessment and Treatment Objectives Begin outpatient rehab 2 weeks post discharge Outcome measures TUG and LEFS, NPRS, PSFS Review and progress pathway exercises Review hip precautions and/or WBing status ie. 50% Gait assessment and progression of gait aid as appropriate (ie. walker to crutches) Ensure patients are safe, compliant and independent with post-operative exercises and mobility At first appointment decide if patient is reliable to continue with home program until 6 week followup with surgeon Week 6 Milestones Patient ambulating with one cane or less if WBAT post-op Minimal Trendelenburg in static single leg standing but may still be present with ambulation if WBAT post-op Hip abduction: Grade 2+ TUG 20 secs LEFS 30 Week 6 Treatment Objectives Initiate against gravity hip abduction Begin single leg activities and stair exercises if WBing status changed to as tolerated at 6 wks Progress resistance and difficulty of home exercise program Individualize exercise program for return to work if appropriate Proprioception and endurance Strengthening, especially hip abductors Gait assessment and progress aid as able Week 9-12 Discharge Indicators TUG 12 secs No Trendelenburg with ambulation Hip abduction: Grade 3+ Independent Mobility 4

5 Discharge with CCAC pathway for TKA (Visits dependent on achievement of milestones) Assessment within 1-5 days of discharge from Acute Care Review post-operative exercises Outcome measures TUG, LEFS, NPRS, ROM and quads lag Gait assessment and training Home environment Treatment Objectives Continue with ROM exercises Continue management of pain and swelling Progress strengthening and flexibility exercises as able Proprioception exercises Progression of gait to no aid or to preoperative gait aid Endurance Safety and management within home environment Independent gait with crutches or cane on level ground (depends on pre-operative gaid aid needs) Able to safely enter and exit home Able to safely transfer to vehicle LEFS 20 If patient achieves milestones at week 2, patient discharged from CCAC services and referred to Outpatient rehab clinic if needed. If milestones not met continue with CCAC services. Week 4 Milestones LEFS 30 TUG 20 secs Independent mobility with or without gait aid on level ground Able to safely enter and exit home Able to transfer safely to vehicle If patient achieves milestones at week 4, patient discharged from CCAC services and referred to Outpatient rehab clinic if needed If milestones not met, continue with CCAC services. Week 6-12 Milestones TUG 10 secs Independent mobility ROM 110 o of flexion 5 o of Extension No quads lag Grade 4 quads strength Criteria for Discharge Above criteria are met Above criteria are not met but doubtful further CCAC or outpatient will help achieve outcomes 5

6 Discharge with CCAC pathway for THA (Visits dependent on achievement of milestones) PT Assessment and Treatment Objectives Initial assessment within 1-5 days post discharge from Acute Care Outcome measures TUG and LEFS, NPRS Review and progress pathway exercises Review hip precautions and/or WBing status ie. 50% Gait assessment and progression of gait aid as appropriate (ie. walker to crutches) Ensure patients are safe, compliant and independent with postoperative exercises and mobility Home environment assessment OT Assessment and Treatment Objectives Initial assessment within 1-3 days post discharge from Acute Care Review strategies for management of basic ADLs Re-enforcement of joint protection strategies Follow-up re: equipment needs and home accessibility Address home safety concerns ie. cognitive status, falls risk, etc. Able to retain and apply info re: restrictions and/or WBing consistently Independent with ambulation with appropriate gait aid Able to enter and exit home safely with available level of support Able to transfer to vehicle safely and independent to vehicle TUG 35 secs LEFS 15 6 Week 6 Milestones Patient ambulating independently Able to safely enter and exit home with available level of support TUG 20 secs LEFS 30 If patient achieves milestones at week 6, patient discharged from CCAC services and referred to Outpatient rehab clinic as appropriate. If milestones not met continue with CCAC services. Week 6 Treatment Objectives Initiate against gravity hip abduction Begin single leg activities and stair exercises if WBing status changed to as tolerated at 6 wks Progress resistance and difficulty of home exercise program Individualize exercise program for return to work if appropriate Proprioception and endurance Strengthening, especially hip abductors Gait assessment and progress aid as able Week 9-12 Milestones TUG 12 secs No Trendelenburg with ambulation Hip abduction: Grade 3+ Independent Mobility

7 If patient achieves milestones at week 2, patient discharged from CCAC services and referred to Outpatient rehab clinic. If milestones not met continue with CCAC services. Week 4 Milestones Independent ambulation with appropriate gait aid Able to enter and exit home safely with available level of support LEFS 25 Criteria for Discharge Above criteria are met Above criteria are not met but doubtful further CCAC or outpatient will help achieve outcomes If patient achieves milestones at week 4, patient discharged from CCAC services and referred to Outpatient rehab clinic as appropriate If milestones not met continue with CCAC services. 7