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NPTEFF Rehab Protocols

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Atanu Kumar Nayak
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33 views

NPTEFF Rehab Protocols

Uploaded by

Atanu Kumar Nayak
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NPTE FINAL

FRONTIER:
Rehab Protocols
Josh Madonick, PT, DPT, CSCS
Bhupinder Singh, PT, PhD

Objectives
• To understand the necessary rehabilitation protocols,
precautions to abide by, and different approaches for: •
Anterior, Antero-lateral, and Posterior Total Hip Replacement •
Total Knee Replacement
• Total Shoulder replacement
• Rotator Cuff Repair
• SLAP Repair
• Wrist and Ankle Tendon Repairs

Anterior/Anterolateral
Total Hip Arthroplasty
• Dislocation precautions to avoid:
• Avoidance of hip flexion > 90 degrees
• Avoidance of hip extension, adduction, and ER past neutral •
Avoidance of combined motions of abduction, flexion, and ER of
hip
• Lower dislocation risk than Posterior approaches

Posterior/Postero-lateral
Total Hip Arthroplasty
• Dislocation Precautions to avoid:
• Hip adduction past neutral
• Hip IR past neutral
• Hip flexion past 90 degrees

• While these approaches will likely restore gait pattern quicker,


they place the patient at highest risk for dislocation

Protocol for THA


• Phase 1: Maximal protection
• Education to patient/caregiver to avoid precautions
• Usually WBAT
• Ankle pumps to prevent DVT formation
• Monitor for possible infection
• Maximize Functional mobility (bed mobility, transfer training,
appropriate trunk mechanics when sit to stand to avoid violating
dislocation precautions)
• Strengthen UE’s for assistance with daily tasks
• Avoid hip flexion contracture

Protocol for THA


• Stage 2: Typically begins 4-6 weeks post-op
• Regain strength and muscular endurance
• Strengthen hip abductors and ER’s
• Improve CV and Pulmonary endurance
• Restore ROM within dislocation precautions
• Improve postural stability, balance, gait

• Stage 3: Begins around 12 weeks post-op


• Extended rehab and modification of activities if necessary
• Ensure good strength of hip abductors and ER’s • Return
to sport and higher level activities

Total Knee Arthroplasty


• Relatively high success rate
• Lower risk than THA
• Usually WBAT unless a cementless fixation is used
(uncommon)
Total Knee Arthroplasty
• Stage I (Weeks 1-4)
• Control postoperative swelling
• Minimize pain
• Control for DVT and infection development
• Increase ROM to 0-90 (Extension priority!)
• 3/5 to 4/5 strength of quadriceps
• Ambulate with or without assistive device
• Establish HEP

• Intervention
• Ankle pumps
• Quad/Hamstring/Abductor/Adductor Setting
• Gait Training
• Patellar Mobilization
Total Knee Arthroplasty
• Stage II (Weeks 4-8)
• Reduce swelling
• ROM 0-110
• 4/5 to 5/5 strength in all LE musculature
• Unrestricted ADL function
• Improve balance, functional mobility, neuromuscular control

• Interventions
• Patellar mobilization
• LE stretching
• Closed chain strengthening and PRE’s
• Tibiofemoral joint mobilization if needed
• Proprioceptive training
• Aerobic exercise (cycling, swimming, walking)
Total Knee Arthroplasty
• Stage III (Week 8 onward)
• Develop maintenance program
• Community ambulation
• Improve cardiopulmonary endurance and aerobic fitness training

• Interventions
• Same as Stage II with progressions
• Progress balance and advanced functional activities
• Exercises specific to sport or higher level activity

Total Shoulder Arthroplasty


• The most important thing to note on a TSA is whether or not
rotator cuff repair was performed
• If so, sling will be needed for at least 4-6 weeks
• If not, sling will be weaned off within the same day as surgery

• The two most prominent forms of shoulder arthroplasty are


the intact rotator cuff TSA and the reverse TSA

Intact Cuff TSA


• Phase I (Weeks 0-4)
• Elevation of the arm restricted to < 120 degrees
• ER of arm restricted < 30 degrees (with arm at side)
• Grade I/II joint oscillation
• AROM scapular and elbow
• PROM and AAROM
• AAROM in supine for first 3 weeks
• At week 4, can transition to sitting/standing
• No active IR for AT LEAST 6 weeks (protect subscapularis repair)
• Pendulum exercise
• Light, NWB isometrics of shoulder muscles in scapular plane

Intact Cuff TSA


• Phase II (Weeks 4-12)
• Continue AROM
• No GH extension past neutral (up to 6 weeks)
• Gradually increase GH rotation
• Gentle stretching after 6-8 weeks
• Improve function of rotator cuff and scapular stabilizers •
Submaximal isometrics of GH muscles with light weight bearing
through UE
• Delay resisted rotation for several weeks (if non-intact cuff)
• Progress to low-resistance dynamic strengthening

Intact Cuff TSA


• Phase III (12+ weeks)
• Combined adduction, internal rotation, and extension permitted
• Progress end range self stretches
• Progressive resistive exercises in functional patterns
• Closed chain stabilization

Reverse TSA
• Phase I (0-6 weeks)
• Abduction splint (24 hrs/day for < 3 but < 6 weeks)
• No GH extension or IR past neutral
• 0-20 of ER and up to 90-120 elevation in scapular plane
• Once immobilizer can be removed:
• Grade I/II oscillations
• AROM of scapula and elbow
• Pendulum
• PROM only of GH joint
• Only light, NWB isometrics of scapular stabilizers and deltoid

Reverse TSA
• Phase II (6-12 weeks)
• No GH extension or IR past neutral
• 0-20 ER and up to 90-120 arm elevation in scapular plane
• Increase PROM while observing above
• AAROM (begin in supine, progress to sitting)
• Improve function of deltoid/scapular stabilizers
• Submaximal isometrics (NWB only)
• Delay resisted rotation for several weeks
• Progress to low-resistance, dynamic strengthening of elbow/wrist
towards the end of this phase

Reverse TSA
• Phase III (Weeks 12+)
• Gentle stretching within motion restrictions
• Begin closed chain stabilization
• Progress UE PRE’s in functional patterns

Rotator Cuff Repair


• Passive or assisted ROM within SAFE and PAIN-FREE ranges
based on surgeon's report
• Only passive, non-assisted ROM for 6-8 weeks after repair •
Initially performed in supine with progression to sitting/standing •
Minimize superior/anterior translation of humeral head • Do
not allow active shoulder flexion/abduction until patient can
lift arm without hiking shoulder

Rotator Cuff Repair


• Strengthening
• Isometric scapular stabilizer strengthening with arm supported
• No weight bearing for 6 weeks
• Delay dynamic strengthening for minimum of 8 weeks • Avoid ER
in this time frame for supraspinatus/infraspinatus repairs • Avoid IR
in this time frame for subscapularis repairs

• Stretching
• Avoid vigorous stretching, contract-relax, or grade III+
mobilizations for at least 6 weeks
• If supraspinatus/infraspinatus, avoid stretching into IR
• If subscapularis, avoid stretching into ER

SLAP Repair
• Limit passive or assisted elevation of arm to 60 degrees for
first 2 weeks, and up to 90 degrees at 3 to 4 weeks post-op •
Perform only passive assisted humeral rotation with the
shoulder in scapular plane for first two weeks
• ER to neutral, IR to 45
• During weeks 3-4, progress ER up to 30 and IR to 60 • Avoid
positions that create tension in biceps (elbow extension with
shoulder extension) during first 4-6 weeks
• Postpone active elbow flexion for 6 weeks and resisted biceps
exercises until 8-12 weeks
• Avoid positions of abduction combined with ER (places stress
on biceps insertion on to glenoid)

Wrist- Flexor Tendon Repair


• Wrist is immobilized after surgery for up to 5 days, unless
prolonged immobilization is necessary
• Zone I,II,III repair immobilization- 10° to 45° of wrist flexion
and from 40° to 70° of MCP flexion with the IP joints in full but
comfortable extension
• Exercises approaches to maintain tendon-gliding and prevent
adhesions :
-Early controlled passive motion
-Early controlled active motion

Flexor Tendon Repair


PHASE 1 (Up to 3-5 weeks)
• Passive MCP, PIP, and DIP flexion and extension of each individual
joint
• Place and hold exercises
• Minimum-tension, short-arc motion

PHASE 2 (4 to 8 weeks)
• Aim –Safely increase stress on the repaired tendon & achieve full
active flexion and extension of the wrist & glides of the tendons •
Place-and-hold exercises with gradual increase in tension

Flexor Tendon Repair


• Active ROM - Flexion & extension of the IP joints with the MCP joints
flexed, MCP flexion/extension with IP joints relaxed, and active wrist
flexion and extension with fingers relaxed
• Initiate tendon-gliding and blocking exercises at 5-6 weeks

• PHASE 3 (8 weeks)
• Resistance exercises to improve strength and endurance
• Dexterity exercises
• Use of the hand for light (1 to 2 lb) functional activities

Extensor Tendon Repair


• Immobilization in an extended position. For zone III/IV repair,
the PIP and sometimes the DIP joints are placed in extension,
but for a zone V/VI repair, the wrist is held in 30° of extension
and the MCP joints in 30° to 45° of flexion.

• Early Controlled Active Motion Approach (Central slip repair)


• Exercise is performed with finger splint.
• E.g. One splint is molded to limit PIP flexion to 30° and DIP flexion to
20° or 25° and the other splint is fabricated to hold the PIP joint in
full extension during isolated DIP flexion limited to 30° to 35°.

Extensor Tendon Repair


• End of 4 weeks, the patient achieves 70° to 80° of active flexion &
full extension of the PIP joint.
• Composite MCP, PIP, and DIP flexion – At 4 weeks or when the
exercise splints have been discontinued.
• By 6 to 8 weeks- low-intensity resisted exercises, gradual use of the
hand for functional activities

• Delayed Mobilization Approach


• Exercises are delayed for at least several weeks after surgery and
depends on the extensor tendon zone
• Resisted exercises are not initiated until 8-12 weeks

Achilles Tendon Repair


• Weight bearing
• Conventional Approach- Six weeks immobilization and non-weight
bearing
• Early Remobilization Approach- immediately after surgery or after 1
or 2 weeks

• PHASE 1 ( Up to 4 to 6 weeks )
• Active ROM of non-immobilized joints
• Muscle setting exercise of dorsiflexors, invertors, evertors and
plantarflexors (at 2 weeks).
• Weight-shifting activities in bilateral stance while wearing the
orthosis (when partial weight bearing is permitted)
Achilles Tendon Repair
• PHASE 2 (4-6 weeks to 12 weeks)
• Weaning from orthosis
• Grade III joint mobilisation techniques
• Self-stretching and active ROM exercises
• Strengthning exercise - OKC of hip, knee, ankle and CKC like heel
raise (B/L to U/L)
• Balance training wearing functional orthosis
• Gait training and cardiopulmonary exercises

• PHASE 3 (After 12 to 16 weeks)


• Return to pre-injury level
• Strength and muscular endurance training
• Plyometric training and treadmill walking on an incline, advance
training

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