Evidence-Based
for the Total Knee Replacement
Instructor: Andrea Salzman, MS, PT
Lab demonstrations: Kim Gordon, MPT
Aquatic Therapy
Instructor: Andrea Salzman, MS, PT
University of Alabama
at Birmingham grad
Awarded APTA’s highest honor
for aquatic PTs in 2010
Aquatic Therapy University,
Director of Programming
Founder and Owner,
Aquatic Resources Network
Has served as:
•
Editor-in-Chief, Journal
•
Therapy Pool Manager
•
Adjunct Faculty, PT School
•
Functional Design Consultant
•
Instructor, over 200 conferences
•
Aquatic Health Research Database (AHRD) Creator
•
Author, 5 aquatic therapy-related texts
•
Columnist, 6 magazines, over 300 articles
#1. Understand, from the physician's perspective, under what
circumstances it would be appropriate to begin aquatic therapy as
early as 5-7 days post-operatively. Examine the literature that
bolsters that argument.
#2. Describe why aquatic therapy may be the treatment of choice if (a) the patient demonstrates an abnormal gait pattern or the need for an assistive device post-operatively due to pain or weakness, (b) the patient is experiencing post-operative edema limiting ROM (c) the patient is unable to exercise in a gravity-dominant environment.
#3. View and discuss a 20-minute aquatic treatment plan for the post-operative treatment of a total knee replacement.
#4. Document medical necessity for aquatic therapy and locate what payers (including Medicare) have to say about its use for the pre- and post-operative total joint replacement patient
#5. Be able to identify and locate supportive research to bolster case.
Objectives
Contact
….. [email protected] | www.swimatu.com
Understand when it’s
appropriate to begin
aquatic therapy early
.
#1.
The complication rate for total knee replacement surgery is low.
Most problems are minor and easily treated. Major complications
occur in less than 2% of cases.
Possible surgical complications include:
•
Blood clots
•
Loosening of implant
•
Stiffness
•
Continued pain
•
Neurovascular injury
•
Infection
A Surgeon’s Fears
Peri-prosthetic
infections
are feared and severe
complications.
A Surgeon’s Fears
Deep infection
accounts for
roughly 20%
of TKA revision
operations.
A Surgeon’s Fears
Source: Register Tska, Annual Report 2010, L. Lindgren, M. Sundberg, A. W-Dahl, O. Robertson, (Eds.), Department of Orthopedics, Lund Hospital, Lund, Sweden, 2010.
The reported
incidence lies
between
0.5 and 1%.
A Surgeon’s Fears
Sources: E. Jamsen, M. Varonen, H. Huhtala et al., “Incidence of prosthetic joint infections after primary knee arthroplasty,” Journal of Arthroplasty, vol. 25, no. 1, pp. 87–92, 2010.
A. Stefansdottir, D. Johansson, K. Knutson, L. Lidgren, and O. Robertsson, “Microbiology of the infected knee arthroplasty: report from the Swedish Knee Arthroplasty Register on 426 surgically revised cases,” Scandinavian Journal of Infectious Diseases, vol. 41, no. 11-12, pp. 831–840, 2009.
Impact on Patient
Devestation
Impact on MD
http://www.ratemds.com/doctor-ratings/Impact on $$$
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3349123/Additional treatment costs (avg) of a single infected total
joint prosthesis for medical and surgical treatment:
A. $10,000
B. $20,000
C. $30,000 and more
D. 100,000
Quiz
Additional treatment costs (avg) of a single infected total
joint prosthesis for medical and surgical treatment:
A. $10,000
B. $20,000
C. $30,000
D. 100,000
Impact on Economy
R. O. Darouiche, “Treatment of infections associated with surgical implants,” New England Journal of Medicine, vol. 350, no. 14, pp. 1422–1429, 2004.
…caused by infected joint prosthesis & fracture
fixation devices in USA.
Roughly
$1.8 billion per yr
additional costs…
R. O. Darouiche, “Treatment of infections associated with surgical implants,” New England Journal of Medicine, vol. 350, no. 14, pp. 1422–1429, 2004.
…caused by infected joint prosthesis & fracture
fixation devices in USA.
Roughly
$1.8 billion per yr
additional costs…
R. O. Darouiche, “Treatment of infections associated with surgical implants,” New England Journal of Medicine, vol. 350, no. 14, pp. 1422–1429, 2004.
Impact on Economy
Is immersion
safe
post-operatively?
Are you increasing the risk of infection?
The Question…
http://www.archives-pmr.org/article/S0003-9993%2812%2900590-4/fulltext
http://www.archives-pmr.org/article/S0003-9993%2811%2900843-4/fulltext
The Science
Tegaderm
The following site is a PDF of 3M tegaderm
transparent dressing how to apply and
remove, including patient handout.
http://tinyurl.com/3ogbbhy
•
Huge, unprecedented increase in joint replacements…
a potential doubling of numbers between 2010 and 2016.
Fast Facts
Year
1993
2005
% change
THA
135K
238K
175%
#1. Understand, from the physician's perspective, under what circumstances it would be appropriate to begin aquatic therapy as early as 5-7 days post-operatively. Examine the literature that bolsters that argument.
#2. Describe why aquatic therapy may be the treatment of choice if (a) the patient demonstrates an abnormal gait pattern or the need for an assistive device post-operatively due to pain or weakness, (b) the patient is experiencing post-operative edema limiting ROM (c) the patient is unable to exercise in a gravity-dominant environment.
#3. View and discuss a 20-minute aquatic treatment plan for the post-operative treatment of a total knee replacement.
#4. Document medical necessity for aquatic therapy and locate what payers (including Medicare) have to say about its use for the pre- and post-operative total joint replacement patient
#5. Be able to identify and locate supportive research to bolster case.
Objectives
Contact
….. [email protected] | www.swimatu.com
Describe why aquatic
therapy may be
the treatment of choice.
#2.
S/p TKR patients are natural candidates for
pool-based treatment. Why?
–
Abnormal gait pattern
–
Excessive use of an assistive device
–
Post-operative edema limiting ROM
–
Unable to exercise in a gravity-dominant environment
•
On a weight-bearing restriction
•
Unable to support his weight to initiate ambulation due to
obesity, weakness or other factors
•
In too much pain to treat on land
What does water bring to the session?
–
Buoyancy
–
Thermal shifts
–
Hydrostatic pressure
–
Viscosity
What does water offer that is
unachievable
on land?
Why Water?
Handout
(PDF)
.…↓ compressive forces
Contact
….. [email protected] | www.swimatu.com
.… ↑ ease of handling & positioning
Thermal shifts
.… ↓ muscle spasm & pain
…. ↓ edema
Slide courtesy Bruce Becker, MD.
Contact
….. [email protected] | www.swimatu.com
…. ↑ cardiac efficiency
Contact
….. [email protected] | www.swimatu.com
…. ↑ safe place to fail
#1. Understand, from the physician's perspective, under what circumstances it would be appropriate to begin aquatic therapy as early as 5-7 days post-operatively. Examine the literature that bolsters that argument.
#2. Describe why aquatic therapy may be the treatment of choice if (a) the patient demonstrates an abnormal gait pattern or the need for an assistive device post-operatively due to pain or weakness, (b) the patient is experiencing post-operative edema limiting ROM (c) the patient is unable to exercise in a gravity-dominant environment.
#3. View and discuss a 20-minute aquatic treatment plan for the
post-operative treatment of a total knee replacement.
#4. Document medical necessity for aquatic therapy and locate what payers (including Medicare) have to say about its use for the pre- and post-operative total joint replacement patient#5. Be able to identify and locate supportive research to bolster case.
Objectives
Contact
….. [email protected] | www.swimatu.com
View a 20-minute aquatic
treatment plan for
post-operative TKR.
- Forwards, backwards, sideways
walking-Manipulate difficulty by
altering buoyancy, velocity,
streamlining, levers, frontal
SA, momentum…
Trunk and hip extension stretch
Chest opening stretch
Hamstring stretch
-- Noodle assisted hamstring and rectus stretches
Straight plane & PNF patterns for the legs
Stepups -(forward, sideways, backwards)
Lowering buttock down steps
Stair bridging (with and without arm raises)
Plantargrade progression
Pilates series of lunges
Aquatic adaptations of the Berg
Balance ball
Scissors
Bicycling
-#1. Understand, from the physician's perspective, under what circumstances it would be appropriate to begin aquatic therapy as early as 5-7 days post-operatively. Examine the literature that bolsters that argument.
#2. Describe why aquatic therapy may be the treatment of choice if (a) the patient demonstrates an abnormal gait pattern or the need for an assistive device post-operatively due to pain or weakness, (b) the patient is experiencing post-operative edema limiting ROM (c) the patient is unable to exercise in a gravity-dominant environment.
#3. View and discuss a 20-minute aquatic treatment plan for the post-operative treatment of a total knee replacement.
#4. Document medical necessity for aquatic therapy and locate what payers (including Medicare) have to say about its use for the pre- and post-operative total joint replacement patient
#5. Be able to identify and locate supportive research to bolster case.
Objectives
Contact
….. [email protected] | www.swimatu.com
Document medical
necessity for aquatic
therapy. Locate what
payers have to say.
Medical Necessity
The physician reviewer found that although
aquatic therapy is…
“
certainly a choice of modality for treatment,
there is no proven benefit over
over
over
over land based PT”
Medical Necessity
#1. Understand, from the physician's perspective, under what circumstances it would be appropriate to begin aquatic therapy as early as 5-7 days post-operatively. Examine the literature that bolsters that argument.
#2. Describe why aquatic therapy may be the treatment of choice if (a) the patient demonstrates an abnormal gait pattern or the need for an assistive device post-operatively due to pain or weakness, (b) the patient is experiencing post-operative edema limiting ROM (c) the patient is unable to exercise in a gravity-dominant environment.
#3. View and discuss a 20-minute aquatic treatment plan for the post-operative treatment of a total knee replacement.
#4. Document medical necessity for aquatic therapy and locate what payers (including Medicare) have to say about its use for the pre- and post-operative total joint replacement patient.
#5. Be able to identify and locate supportive research to bolster case.
Be able to identify and
locate supportive research
to bolster case.
#5.
•
Links to evidence cited
•
5 page “Indications” for AT
download (PDF)
•
Link to how to apply Tegaderm
•
Link to order “Justifiable AT for
the THR/TKR manual”
Online:
Download at….. www.swimatu.com/TKR13 (Available for 72 hrs after webinar)
