Modification and Adjustment

By

Dr. Magdy shabana

Senior staff physical therapist Orthopedic department

Kaser elaini Cairo University Hospital

PHYSICAL THERAPY REHAB PROTOCOL POST TOTAL HIP REPLACEMENT (THR)

Postoperative day 1 o Bedside exercises are initiated (eg, ankle pumps, quadriceps sets, gluteal sets)
o o

Review of hip precautions and weight-bearing status Bed mobility and transfer training (ie, bed to/from chair)

Postoperative day 2
o

Gait training is initiated with use of assistive devices (eg, crutches, walker) and with the determined weight bearing precautions. Continue functional transfer training

Postoperative day 3-5

o

Progression of ROM and strengthening exercises to hip flexor and abductor within the patient's tolerance Progression of ambulation on level surfaces and stairs (if applicable) with the least restrictive device Progression of ADL training

****This protocol is applicable to all types of hip surgery with specific considerations regarding
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the approach, type of implant and the weight bearing precaution.

PHYSICAL THERAPY PROTOCOL POST TOTAL KNEE REPLACEMENT

Physical therapy rehabilitation fro knee replacement is sometimes a slow process, because of age constrainsts and th fact that the hips or other knee may also be involved in an arthritic process. Patient needs to start to learn about rehabilitation before having the knee replacement as the following : -Preoperative 1-2 weeks prior to surgery
o o o

Education on the surgical process and outcomes Instruction on a postoperative exercise program Assessment of the home environment

It is worth visiting a physiotherapist some weeks before to learn:

how to walk with crutches how to do quads sets and sitting extensions steps for rehabilitation after surgery.

Post-operative physical therapy in-pt protocol

***After surgery, rehabilitation focus on regaining range-of-motion and rebuilding quads and hamstrings strength.
Total knee replacement exercise protocol

Postoperative day 1 o Bedside exercises (eg, ankle pumps, quadriceps sets, gluteal sets) o Review weight-bearing status o Bed mobility and transfer training (ie, bed to/from chair) o CPM to be adjusted and set up for the reached ROM. Postoperative day 2 o Exercises for active ROM, active-assistive range of motion (AAROM), and terminal knee extension o Strengthening exercises (eg, ankle pumps, quadriceps sets, gluteal sets, heel slides, straight leg raises, isometric hip adduction)
o

Gait training with assistive device and functional transfer training (eg, sit to/from stand, toilet transfers, bed mobility) CPM to be conyinued to reach 90 of knee ROM

Postoperative day 3-5 (or on discharge to rehabilitation unit) o Progression of ROM and strengthening exercises to the patient's tolerance

o o

Progression of ambulation on level surfaces and stairs (if applicable) with the least restrictive device Progression of ADL training

PHYSICAL THERAPY REHAB PROTOCOL POST MEDIAL COLLATERAL LIGAMENT (MCL)

1-2 Weeks

Initiate physical therapy as follow:

1- Rx. of modalities for pain and swelling as needed. 2Easy stationary bike for range of motion (ROM's), 3- Quads, straight leg raises (SLR's), calf raises. Gentle ROM's. 4- No valgus stress or open chain for 6 wks. No inside leg raise. Ligament needs time to heal. When working adductors stress point should be superior to knee or work them in functional position later in progression.
5-

Generally, immobilizer is D/C'd at 2 weeks pending physician exam.

PHYSICAL THERAPY REHAB PROTOCOL POST MENISCECTOMY REHABILITATION

Post-op visit Number One at I week post-op:

Evaluation of limitations in: Comfort level/Pain Rating on 1/10 scale Guarding/apprehension with wt bearing Proprioception ROM Strength VMO quad control Leg control Gait Compliance with p/o care instructions per physician Swelling/Effusion and portal inspection for infection

Criteria for continued PT > I visit : 3 or more of the below deficits require F/U in PT: Pain> 4/10 2+ effusion Partial Weight Bearing secondary to apprehension, pain, poor proprioception Unable to single leg balance > 20 seconds ROM < 5-125 degrees secondary to pain Strength < 4-/5 Poor-fair VMO control Poor leg control with transfer/ADL activities Moderate antalgia with flat surface fwd walking with no
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assistive device Poor compliance with p/o instructions per P.T. and physician ANY SIGNS OF INFECTION REFERRED TO PHYSICIAN IMMEDIATELY formal PT for 2-8 more visits and progression of home program to include: 1Strengthening ex's:
LE Control ex's with emphasis on VMO control Weight shifting progression Single leg balance with trunk shift/challenges T-Band squat progression to step downs for aggressive quad work Gait training FWD Retro High step Lat. shuffle step Instruction in proper bike set-up and resistance level Instruction in leg press, leg curls, and calf raises Pool therapy for strengthening, endurance, and ROM as appropriate Discussion re: appropriate progression through resisted ex's increasing weight, reps, and intensity at each session as tolerated. 2- ROM ex's: Terminal extension hangs Standing terminal extension Flexion stretch in standing and prone Hamstring Stretch 3- Effusion Control: Manual therapy Ice, elevation, massage, and rest intervals throughout the day

Criteria for D/C:

Pain < 2/10 Minimal effusion Full wt bearing with no pain/apprehension ROM: 0- 135 degrees with minimal pain Strength 4+/5 Good VMO control Good leg control with Activities of Daily Living (ADL's)/balance

Test to include:
1- single leg stance > 30 seconds 2- Minimal antalgia (pain) 3-Good compliance with home ex. program and activity modification 4- Return to functional activities without incident 5- Pt able to demonstrate willingness and ability to progress with all exercises at an appropriate pace, adding weight and reps as tolerated.

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P HYSICAL T HERAPY P ROTOCOL P OST A NTERIOR

CRUCIATE LIGAMENT REPAIR

General Considerations: 1-Passive and active range of motion between 30 - 70 degrees for 4 weeks. -Patient will be instructed to come out of the brace once a day for extension range of motion stretching beginning week 2. 2-Crutch assisted weight bearing progressing to as tolerated. 3-Regular attention should be paid to the incisions to decrease fibrosis and scarring--with particular emphasis on the anterior and lateral incisions. 4-Exercises and manual treatments should also focus on early quadriceps and VMO recruitment. 5-Patients are given a functional assessment/sport test at 2, 3, and 4 months post-op.

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day 1-5 post operative PT: 1-Icing and elevation as much as able. 2-Straight leg raise exercises (lying, seated, and standing), quadriceps/adduction/gluteal sets, gait training, passive and active range of motion exercises within guidelines. 3- gait trainig with instructions of assistve device (crutches) use and with weight bearing as tolerated on the affected lower extremity. 4-Balance and proprioception exercises. 5-Soft tissue treatments and gentle mobilization to posterior musculature, patella and incisions.

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PHYSICAL THERAPY REHABILITATION PROTOCOL POST POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

PRE-OP PHYSICAL THERAPY:
PT must begin pre op to give the new graft the best chances of giving a good result by giving education and training for the following.

weight bearing on crutches quads maintenance exercises - quads sets, straight leg raises prone flexion

IMMEDIATE POST-OP PHASE

This period is usually spent in hospital and is focused on reducing pain and swelling, maintaining baseline muscle strength and learning to cope with the CPM machine and crutches.

icing (eg cryocast) static quads with rolled towel under heels gait training with partial weightbearing to weight bearing as tolerated on crutches

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PHYSICAL THERAPY REHABILITATION PROTOCOL POST FROZEN SHOULDER RELEASE

0-2 weeks:
-Sling allowed as needed for comfort only, first 5-7 days, taking arm out often 5-7 times a day for elbow ROM. -Posture education and postural exercises. -Ball or putty squeezing throughout the day. -Icing every two hours for 15-20 minutes first 5-7 days, 3 times a day thereafter. -CPM (constant passive motion) machine 4-6 hours per day for 14 weeks. -Soft tissue mobilization focused on periscapular musculature, cervical spine, and rotator cuff. -Scapular mobilization. -Passive and active assisted ROM manually and using pulley at home going for full motion as soon as able without increased irritability .

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PHYSICAL THERAPY REHAB PROTOCOL POST LARGE ROTATOR CUFF REPAIR

Recommended PT Treatment for:

*Open Repair Large Rotator Cuff Tear *Arthroscopic Repair Large Rotator Cuff Tear 0-2 Weeks Post Op Exercises
Sling at all times, except for exercises PROM limits to: 90 pure abduction, 20 extension, 70 internal rotation (not behind back) 1. Pendulum exercises 3x/day minimum 2. PROM within limits and pain tolerance 3. Elbow and wrist AROM 4x/day minimum 4. Cryocuff/ice: days 1-2 as much as possible, then post activity or for pain

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PHYSICAL THERAPY REHAB PROTOCOL POST MEDIUM ROTATOR CUFF REPAIR

Includes Treatment for:

*Open Repair Medium Rotator Cuff Tear *Arthroscopic Repair Small and Medium Rotator Cuff Tear

0-2 Weeks Post Op Exercises

Sling at all times, except for exercises PROM limits to: 90 pure abduction, 20 extension, 70 internal rotation (also not behind back) 1. Pendulum exercises 3x/day minimum 2. PROM within limits and pain tolerance 3. Elbow and wrist AROM 4x/day minimum 4. Cryocuff/ice: days 1-2 as much as possible, then post activity or for pain

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PHYSICAL THERAPY REHAB PROTOCOL POST ARTHROSCOPIC ACROMIOPLASTY

Includes Treatment for:

*Arthroscopic Acromioclavicular (AC) Joint Excision *Arthroscopic Partial Thickness Rotator Cuff Debridement

0-1 Week Post Op Exercises

Sling worn for comfort 1. Pendulum exercises 3x/day minimum 2. Elbow and wrist AROM 3x/day minimum 3. Cryocuff/ice: days 1-2 as much as possible, then post activity or for pain

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POST-BACK SURGERY PHYSICAL THERAPY REHABILITATION PROTOCOL

*Most people who have spinal surgery experience good to excellent results. * They find significant relief of pain and the return of functional movement and strength, enabling them to walk, sit and cope with the activities of daily life. *Patients often report improvements in the way they feel immediately after they awake from the surgery. * Although many patients see and feel immediate benefits, they maximize the benefits of surgery by taking part in a comprehensive rehabilitation program.

Positioning:
Physical therapist may give pt ideas of ways to position your spine for the greatest comfort. These positions help take pressure of the surgical area by supporting spine and limbs with pillows or towels.

Moving:
Careful movements suggested by Physical therapist can safely ease pain by providing nutrition and lubrication in the areas close to the surgical area. Movement of joints and muscles also signals the nervous system to block incoming pain.

Body Movement:
Using safe body movements which will instructed and tought by Physical Therapist can help pt to avoid extra strain on his/her spine in the weeks after his/her spine surgery.

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Lying in Bed:
Avoid lying in positions that twist or angle pt spine. Don't curl up in the "fetal" position. Choose a firm mattress-not a soft bed or sofa. Keep enough pillows nearby to support your head, shoulders, trunk, and legs. Moving in Bed: When getting in or out of bed, use the "log roll" technique. This is a way to roll to side and sit up while keeping pt spine steady and secure. Instead of twisting pts upper body when roll to one side, try to roll whole body as a unit, like the rolling of a log. Then let legs ease off the edge of the bed toward the floor as pt push his/herself up into a sitting position. This reduces strain from twisting spine, giving the surgical area time to heal.

Sitting:
it depens on surgen protocol for the starting and the precaution to be take when sitting (time of sitting and usage of back brace). Keep spine upright and supported when sitting. A safe, upright posture reduces strain on the spine. Choose a chair that supports your spine. Avoid soft couches or chairs. Place a cushion or pillow behind back while riding in a car. When standing up, keep your spine aligned by leaning forward at the hips.

Bending:
patient may be restricted from bending for a few weeks after spine surgery. Follow surgen's protocol. If pt is given the okay to bend, do so safely. Try to keep back straight and secure as while bending forward keep spine straight. Consider using a "grabber" to avoid bending over at the waist to put on socks, shoes, or pick up items from the floor.

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Lifting:
Surgen and Physical Therapist may restrict pt from lifting or carrying for a period of time after surgery according to protocol.

POST-OPERATIVE PHYSICAL THERAPY PROTOCOL . (during IN-Patient period)

1- bed mobility trainig as turning from side to side.

2- Pt/care giver eduction for on/off back brace if idicated. 3- AROM/STRENGTHENING EXS for upper and lower extramities if pt has developed neuro manifestations. 4- Transefer training in/out of bed as tolerated and with the proper assistance. Pt may sit on chair with back support and for time determine by surgen if the sitting is permited. 5- Gait trainig when possible and per protocol using roller walker and with weight bearing as tolerated.

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POST-OPERATIVE PHYSICAL THERAPY REHAB PROTOCOL FOR SCHEUERMANN DISEASE

Rehabilitation after surgery is more complex. Although some patients leave the hospital shortly after surgery, some surgeries require patients to stay in the hospital for a few days for F/U and to initiate Physical Therapy.

Soon after surgery, a physical therapist may visit patients who stay in the hospital. The treatment sessions help patients learn to move including bed mobility , transefer training and gait training using the proper assistive device and with WBAT and do routine activities without putting extra strain on the back.

***During recovery from surgery, patients should follow their surgeon's instructions about wearing a back brace or support belt. They should be cautious about overdoing activities in the first few weeks after surgery.

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