Effects of Balance Interventions on Elderly Patients after TKR Kelsey Shelton VCU DPT 2016.
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Transcript of Effects of Balance Interventions on Elderly Patients after TKR Kelsey Shelton VCU DPT 2016.
Effects of Balance Interventions on Elderly Patients after TKR
Kelsey Shelton
VCU DPT 2016
Overview
1. Present patient case from Clinical Education II
2. Ask a clinical question
3. Analyze available research
4. Answer the clinical question and relate to patient case
Patient History
• 76 y/o African American female
• Occupation: Retired
• PLOF: Community level with single point cane
• Independent in private residence
• Home Environment: One story house with 3 stairs to enter, bilateral rails
• Admitted to area hospital 5/19 for a L total knee replacement and admitted to skilled nursing facility 5/23
Diagnosis – Total Knee Replacement
• Procedure
• Risks/Complications
• Infection, blood clots, heart attack, stroke, nerve damage
• Recovery
• Average hospital stay – 3-5 days
• Physical therapy to restore function, strength, and ROM
• 1-2 months
Patient History
• Current Medical Hx:
• DM II, HTN, orthopnea, GERD, bilateral peripheral neuropathy in toes, atrial fibrillation
• PMHx
• R shoulder rotator cuff repair 2014, R TKR 2004
Patient Examination/Evaluation
Objective Findings:
• Pt was A&O x4, alert, cooperative
• Safety awareness – Good (safe for home alone, no cues for safety)
• AROM - LLE – knee flexion impaired (76°), knee extension impaired (+10°)
• Strength – RLE – 4/5, LLE – 3-/5
• Sitting Balance – Good
• Standing Balance – Fair
• Bed mobility – Mod I
• Functional transfers – Mod I
• Gait - 150 ft with one rest break
• Stairs – NT
Assessment
GaitSOB and complained of increased pain with ambulation
(8-9/10 VAS scale) Pt negotiated obstacles with CGA Functional Limitation – mobility: walking and moving around Participation Restrictions
Return to home independentPreform community level functional activityAttend Sunday sermon
Treatment Goals Pt goal STG - Patient will increase:
Standing balance to good in order to prepare for gait activities AROM of L knee flexion to 95° to facilitate patient’s ability to
perform ascending/descending 3 stairs with bilateral rails in order to safely return to private residence
L knee extension strength to 4+/5 in order to improve limb stability during gait
LTG: Pt will negotiate obstacles while ambulating with Mod I for
safety while turning in order to return to prior living and supervision levels
Interventions
LE strengthening in all positions
Balance activities Gait training Manual Pt education
Prognosis and Outcomes
Prognosis Good potential to progress towards goals due to prior PT
with R TKR and high prior level of function, good family support, and intact cognition
Outcomes Pt met all goals and was able to ambulate short distances
with SPC with supervision Pt discharged (20 visits) home alone with family support
and enrolled in outpatient orthopedic physical therapy
Clinical Question
Does improving balance in a 70 year old female patient with knee
osteoarthritis after a total knee replacement improve overall functional mobility as assessed through improved
performance on reliable and valid functional outcome measures?
Effects of balance training on functional outcome after total knee replacement in patients with knee osteoarthritis: a randomized
controlled trial Liao et al.
Clinical Rehabilitation, 2013
Objective: To evaluate the effectiveness of additional balance training on mobility and outcome in patients with knee osteoarthritis after a TKR
A prospective intervention study, randomized control trial 113 Participants – 50-85 y/o with tricompartmental,
cemented TKR Experimental group – functional training and additional
balance training vs. control
Liao et al.
Exclusion Criteria
Uncontrolled hypertension
Diabetes BMI > 40 kg/m2 Other lower extremity
orthopedic problems that limited the patient’s function
Neurological impairment
Functional Measures
Distance of functional forward reach
Single leg stance (eyes closed and open)
Sit-to-stand test Stair climbing test Timed 10m walk TUG WOMAC Osteoarthritis
Index
Liao et al.
Interventions
3x per week, one on one with PT
Training Routine (60 min) Warm-up Stretch Mobility exercises Muscle
strengthening Functional task
oriented exercises
Balance (90 min) Side stepping,
braiding, tandem walk, change direction, airex, BAPS, balance beam
Liao et al.
Results: Experimental group scores were significantly better
than those of the control group for all of the outcome measures (p<0.001)
Conclusion: For patients with knee OA receiving a TKR, eight weeks
of additional balance training can improve functional performance in mobility after surgery
An additional balance training program is recommended for the rehabilitation plan
Liao et al.
Limitations: Knee OA Lacked non-intervention control group – result of
natural return of muscle/physical function Dose effect asymmetry Time lapse
Liao et al.
Importance for my patient: Age Gender Knee OA, TKR Diabetes
Functional outcomes of outpatient balance training following total knee replacement in patients with knee osteoarthritis: a randomized
controlled trial Liao et al.
Clinical Rehabilitation, 2015
Objective: To evaluate whether balance training after total knee replacement surgery improves functional outcomes and to determine whether postoperative balance is associated with mobility
A prospective intervention study and randomized controlled trial Follow-up of earlier study – evaluate long term benefits
108 participants (only 5 did not return) Functional Measures
Liao et al.
Results: The balance rehabilitation group exhibited greater
improvement in balance, mobility, and functional outcomes in the 32-week follow-up assessment than the control group who received general functional training
Conclusion The administration of postoperative outpatient balance
training not only improves balance and mobility outcomes immediately after intervention, but also benefits six months after intervention
Liao et al.
Limitations Same authors and population Specific surgeon Lack of definition
Importance to my patient Effect on long term therapy Incorporation into POC
Does improving balance in a 70 year old female patient with knee osteoarthritis after a total knee replacement improve overall functional mobility as assessed
through improved performance on reliable and valid functional outcome measures?
Yes!
Effects of Balance Interventions on Elderly Patients after TKR
Questions?
References
Liao, C., Lin, L., Huang, Y., Huang, S., Chou, L., & Liou, T. (2015). Functional outcomes of outpatient balance training following total knee replacement in patients with knee osteoarthritis: a randomized controlled trial. Clinical Rehabilitation, 29(9), 855-867.
Liao, C., Liou, T., Huang, Y., & Huang, Y. (2013). Effects of balance training on functional outcome after total knee replacement in patients with knee osteoarthritis: a randomized controlled trial. Clinical Rehabilitation, 27(8), 697-709.