Total Knee Arthroplasty (TKA)
The physiotherapy interventions provided for Total Knee Arthroplasty (TKA) condition are mostly post-operative management.Some of the beneficial active physiotherapy interventions for reducing pain, leg activity and range of motion (ROM) for individuals undergone with total knee arthroplasty are accelerated physiotherapy regimens from physical therapy(Pozzi et al., 2013) and strengthening exercises, aqua therapy or hydrotherapy and balance/ proprioception training.However, there is less use of technology assisted physiotherapy.
Physical therapy interventions include range of motion exercise (less than 90 degreesin initial days) (Wilk et al., 2012), exercise for muscle strengths (Halawi et al., 2015) and joint mobilization. These physiotherapy interventions are mostly manual assisted for soft tissue treatments and gentle joints mobilization exercise to the posterior musculature and to gradually improve range of motion.
Hydrotherapy works to develop muscle strength and focus on sensitive joints through directed exercise in an aquatic environment. Through this physiotherapy involvement in TKA conditionthe knee stress and pressure on sensitive joints is relieved by exercising in warm water setting or pool and is help the individual to regain muscle strength gradually.
Balance training or proprioception type of physiotherapy exercise intervention is aimed to help the individual with impaired balance, mobility and movement control and function outcomes for daily activities in individual life.
The joint motions that would be likely to be assessed in patients with total knee arthroplasty condition are the synovial joints such as ball and socket joint e.g. hip, hinge joint, pivot joint, saddle joint and condyloid joint. The synovial joints motions are assessed for angular movements such as knee flexion, knee/leg extension and abduction motion and internal and external rotation.The knee flexion show bending of the leg using knee joint however, the flexion contracture can reduce the knee ability to full straighten. The extension will measure for straightening ability of the individual whereas abduction which be observed for movement away from body center.
The active range of motion (AROM) in normal condition is from 00 to 1400 for extension and flexion respectively (Herbold et al., 2014).The AROM in TKA condition is reduced for the affected knee and leg. The joint motion of knee flexion and knee extension can be expected to have abnormal range or end feel. The expected finding for joint motions are decreased knee flexion and decreased or loss of knee extension. In addition to this, the end feel can be elastic for joint motion of knee flexions while it can be firm in case of knee extension motion of joint. The capsular kind of end feel can be expected which can be described as tissue stretch which can be extended to other muscle tissues which may stretch normally at the end of the passive range of motions (Wilk et al., 2012). This can be observed for the tissues that are stretched along with muscle during hip flexion along with the knee extension. Another end feel that can be expected is muscle spasm where the motion can be halted as it is likely to for the individual that the pain will occur at the end of range as the muscle in spasm will be stretched in further continuing the motion and empty end feelcan be felt for knee flexion as the patient will not allow further extension due to pain.
The muscle groups that are likely to be assessed in TKA condition are hip abductor muscles and thigh muscles(quadriceps) above the knee. As the knee joint is made up lower and upper leg bone which are femur, tibia and knee cap which is patella where TKA procedure involve incision in the knee center which can be troublesome for the quadriceps muscles (Manrique et al., 2015). In addition to this, the partial or total knee replacement surgery affects the muscles adjacent to the knee and hip area which requires assessment of the hip muscles.
The hip muscles and quadriceps muscles might be weak as TKA affect the surrounding knee musculature and reduce in its functional performance and experiences loss of independence. The quadriceps may become weak in providing its role as the primary knee stabilizer (Manrique et al., 2015). These thigh muscles might experience weakness due to direct disturbance from the surgical incision made during the treatment procedure of knee replacements. This causes swelling in the joint which leads to muscle inhibition and causes trauma in the quadriceps muscles (Healy et al., 2013). This effect the overall movement of leg, lifting and walking due to weakenedfunction of these muscles or shutdown of the thigh muscles from the incision trauma of the surgical process.
The hip muscles might also be weak due to trauma from overall surgical process that affects the muscles surrounding the hip that is responsible to being the leg in outward direction i.e. abductor muscles.This surgical trauma affects the hip muscles in providing stability while standing and gait (Healy et al., 2013). Thus, this affects the function performance in standing, climbing stairs and change in position from standing to siting and vice versa.
The research paper by Ferriero et al. (2013) focus on the assessment of the reliability of a smartphone-based(photographic) goniometry for knee joint replacement and to measure the range of motions.The finding of the study recognized that correlations of inter rater and intra rate were greater than 0.958. The study presents that the results were in consensus with the universal goniometer for measurement of knee joint angle which showed limit of agreement to be 95 percent.The study concluded that photographic/smartphone-based goniometry appeared to be a reliable method to measure the angle of knee joint for replacements. The universal goniometer provided width 18.28 of and 14.18.The results showed that inter-rater and intra-rater correlations were always more than 0.958. Thus, the study findings revealed the reliability of smartphone based goniometric assessments for the measuring of knee joints and range of motions in clinical practices. Thus, for the determination of inter and intra reliability the goniometer can be used as a measurement method.
The smartphone-based goniometer can bear an impact on the evaluation as it provides an alternative to traditional joint goniometry used for clinical setting by using an image to reveal the degree of limitation associate with each joint motion. This is useful to get the inter-rater and intra rater reliability and to determine the correlation. The inter-rater reliability and correlation can be compared with the clinical observations for knee joint angles. The patients knee joint angle can be measured reliably by using photographic application-based goniometer for knee flexion and active extension instead of clinical measurements.
The functional outcome measure selected for total knee arthroplasty is performance measure to measure physical impairment for muscle strengthening from joint motions. The research by Skoffer et al. (2015)focus on functional performance of muscle strength associated with two joint motions in patients with condition of total knee arthroplasty. This study investigates on the effect of resistance training which is provided as pre-operative management on functional performance and muscle strength post-operative surgery. In this controlled study, the population for this test were fifty-nine patients from a Denmark hospital. The study in its several test procedures made use of goniometry assessment for the affected knee to measure the active and passive joint motion of knee flexion and extension range of motions (ROM). To measure active ROM, the patient himself/herself was asked to flex and extend the knee/leg till it was possible whereas the patient was flexed and extended by the assessor until the paint asked to stop to measure passive ROM. The goniometer fulcrum was paced over synovial joint (lateral epicondyle) pointed towards femur bona and other towards lateral malleolus. The mean value of ROM for active and passive knee flexion ROM was 119.7 and 124.2respectively and ROM for active and passive knee extension was 5.9 and 4.1 respectively. The study recognizes that muscle strength in case of knee extensor was found weaker in only affected leg while knee flexor muscle strength was comparable in both affected and non-affected leg. Thus, for the performance-based outcome measure the knee joint range of motion was measured through goniometry measurement and has been found to have adequate reliability with correlated coefficient. The study highlight that both the joint motions were related to performance-based measures. The study alsoput forwards that this goniometer method holds validity and reliability in patients with the condition of knee replacement.
Ferriero, G., Vercelli, S., Sartorio, F., Lasa, S. M., Ilieva, E., Brigatti, E., … &Foti, C. (2013). Reliability of a smartphone-based goniometer for knee joint goniometry. International journal of rehabilitation research, 36(2), 146-151.
Halawi, M. J., Vovos, T. J., Green, C. L., Wellman, S. S., Attarian, D. E., &Bolognesi, M. P. (2015). Preoperative predictors of extended hospital length of stay following total knee arthroplasty. The Journal of arthroplasty, 30(3), 361-364.
Healy, W. L., Della Valle, C. J., Iorio, R., Berend, K. R., Cushner, F. D., Dalury, D. F., &Lonner, J. H. (2013). Complications of total knee arthroplasty: standardized list and definitions of the Knee Society. Clinical Orthopaedics and Related Research®, 471(1), 215-220.
Herbold, J. A., Bonistall, K., Blackburn, M., Agolli, J., Gaston, S., Gross, C., … &Babyar, S. (2014). Randomized controlled trial of the effectiveness of continuous passive motion after total knee replacement. Archives of physical medicine and rehabilitation, 95(7), 1240-1245.
Manrique, J., Gomez, M. M., &Parvizi, J. (2015). Stiffness after total knee arthroplasty. J Knee Surg, 28(2), 119-126.
Pozzi, F., Snyder-Mackler, L., &Zeni, J. (2013). Physical exercise after knee arthroplasty: a systematic review of controlled trials. European Journal of Physical and Rehabilitation Medicine, 49(6), 877–892.
Skoffer, B., Dalgas, U., Mechlenburg, I., Søballe, K., &Maribo, T. (2015). Functional performance is associated with both knee extensor and flexor muscle strength in patients scheduled for total knee arthroplasty: A cross-sectional study. Journal of rehabilitation medicine, 47(5), 454-459.
Wilk, K. E., Macrina, L. C., & Arrigo, C. (2012). Passive range of motion characteristics in the overhead baseball pitcher and their implications for rehabilitation. Clinical Orthopaedics and Related Research®, 470(6), 1586-1594.