1. A CASE REPORT OF NERVE DAMAGE AND KNEE EXTENSOR WEAKNESS AS A RESULT OF A TKA Robert Whittaker, SPT University of North Dakota

2. Patient Presentation 49 y.o. female with (L) TKA in 2009 who suffered a fibular nerve palsy as well as having the quads “shut down” Patient evaluated on 10/20/13 for posterior knee pain & discharged on 12/9/13 for a total of 5 visits. Patient private pay & had 20 independent visits to clinic gym Pt. instructed on home NMES use & to use clinic’s gym to recumbent bike, leg press/extension/curls with emphasis on eccentric contraction for duration of rehab. Pt. progressed from lacking 50° of AROM (L) knee extension to lacking ~35° with some improvement in pain. Referred to physician for genetic testing for nerve disease & nerve conduction test of femoral nerve (HNPP?). Pt. stated she was looking into getting a knee brace.

3. Clinical Decision Making

4. Patient Care Accept Familiar with TKAs and protocols, treatment appropriate for pt. to regain strength Skills to improve quadriceps weakness, seen multiple TKAs in clinicals Direct Goals, extent of condition, patients availability, handling techniques Indirect Private pay, travel in winter, can do HEP, pain, past therapy, PMH, life Refer Refer back to MD eventually from little progress

5. History Patient is full time homemaker (military wife?) C/O constant (L) posterior knee pain 5/10 Patient has to lift her leg into car and leg gives out often Pain and weakness in left leg cause her to ambulate with SPC (R) knee pain secondary to DJD and hasn’t walked well for years Pt. wore an AFO to ambulate after TKA but no longer wears Also has neck & low back pain due to bulging discs Indicated she has diabetes, thyroid trouble, arthritis, sleeping problems, frequent headaches, & degenerative joint disease for many years Many imaging studies (none available)

6. Pain Drawing

7. History Cont’d Medications: Aspirin (81mg), Inderal (120mg), Janumet XR-50/100xz), Lipitor (20mg), Lisinopril (40mg), Omeprazole (20mg), Synthroid (50mcg), Topamax (100mg), Zyrtec (10mg) Allergy Meds: Penicillin, Ampicillin, Bactrim, Celocin, Feldene, Zomig Family history: Her father had a myocardial infarction (MI) as well as COPD. Her mother has prediabetes. Both her parents have high blood pressure.

8. Past Medical History Cholecystectomy (1991) (L) Carpal Tunnel release (1998), (R) release (1999) 2008 Cortisone Shots (March & July) Arthroscopy & meniscectomy (June) Arthroscopy, chondroplasty, partial meniscectomy (Dec) 2009 Orthovisc and cortisone shots (Jan-Sep) TKA (Oct) with fibular nerve palsey  knee manipulation (Dec) PT – ionto, e-stim, strength (Nov – May 2010) 2010 EMG Nerve Study on Fibular/Femoral Nerve (June) LLE Inching study fibular nerve (Oct) 2011 Fibular nerve release, knee manipulation (may) More PT (14 sessions for IT band and fibular nerve pain) (Oct) 2012 More PT (12 sessions for fibular nerve and posterior knee pain) (Feb) EMG nerve study (Nov) 2013 Epidural steroid injection (Jan)

9. Examination – Systems Review Initial Eval (10/20) Weight 190lbs, 61.5” (BMI 36) Mature scaring on anterior knee from TKA, posterolateral knee from fibular nerve release, small scars on wrists from carpal tunnel releases AROM: (L) knee ext -50° sitting. (L) ankle AROM appears to be WFL PROM: 110° (L) knee flexion, 0° (L) knee. Strength: 4/5 (L) knee flexion, 2/5 (L) knee extension 11/15 AROM: -35° left knee ext Discharge (12/14) AROM: -38° left knee ext. PROM (L) ankle DF 7° Strength: Hip flexion 4/5 (B), (R) ER 3/5 (pain felt in her knee when resisted), (L) ER 4/5, (R) IR 5/5, (L) IR 3/5 (pain felt on lateral knee), and 4/5 for (L) hip abd/add/ext. (L) ankle eversion 3/5 (pain in lateral knee), 4/5 DF/PF/INV. Palpation: (L) vastus lateralis, lateral gastrocnemius head, and distal biceps femoris were tender to palpation RHR 60 BPM, BP 124/76, SaO 2 98%. Dermatomes L 1 -L 3 feel same (B), L 4 -S 2 diminished sensation to touch on (L) compared to (R) Reflexes: (R) L 3 & S 1 normal, (L) L 3 & S 1 diminished Special Test: (+) varus stress test

10. Trigger Points 13

11. Rigor – Assessment 8 Varus Stress Test 18 20-30° Flexion: LCL, posterolateral capsule, arcuate-poplitus complex, ITB, biceps femoris tendon Extension: fibular or lateral collateral ligament, arcuate-popliteus complex, biceps femoris tendon, PCL, ACL, lateral gastrocnemius muscle, ITB Article: investigated reliability of multiple knee clinical tests in CE, EUA, and by comparing to arthroscopic techniques 6 (+) in CE, 10 (+) EUA (p=0.0277, Wilcoxon) Limited to collateral ligament tear: 4 subjects, 1 instability found in CE and 3 EUA Sensitivity = 25%, Specificity not reported

12. ICF Model

13. ICF Model Cont’d Health Condition (L) Dysfunctional Quadriceps, (L) fibular nerve dysfunction, (R) knee DJD Body Structures/Function (impairments) ROM: (L) knee ext -50° sitting. PROM: 110° (L) knee flexion, 0° (L) knee. (L) ankle AROM appears to be WFL. *(L) ankle DF PROM 7° Strength: 4/5 (L) knee flexion, 2/5 (L) knee extension. *Hip flexion 4/5 (B), (R) ER 3/5 (pain felt in her knee when resisted), (L) ER 4/5, (R) IR 5/5, (L) IR 3/5 (pain felt on lateral knee), and 4/5 for (L) hip abd/add/ext. (L) ankle eversion 3/5 (pain in lateral knee), 4/5 DF/PF/INV. *Dermatomes L 1 -L 3 feel same (B), but L 4 -S 2 diminished sensation to touch on (L) compared to right *Reflexes: (R) L 3 & S 1 normal, (L) L 3 & S 1 diminished Posterior (R) knee pain (5/10) *Vastus lateralis, lateral gastrocnemius head, and distal biceps femoris were tender to palpation – guarding/trigger points? *Laxity in lateral knee Excessive BMI Scars

14. ICF Model Cont’d Activities Ambulates independently with SPC Can transfer into/out of car with difficulty Participation No mention of being able to not participate in what she desires If health condition not addressed may possibly lead to further deterioration in QOL  need for assistive equipment, TKA revision/other knee, amputation from diabetes? Contextual Personal Factors (internal) motivated to get better, pessimistic, pain in other knee/neck/back Environmental Factor (external) Husband/family?, home, weather

15. Evaluation Initial Evaluation The patient presents with (L) knee weakness with decreased PROM/AROM with increased pain with motion. The patient’s functional mobility is decreased and will be instructed on a gym program and how to operate a home NMES unit to improve quadriceps activation and knee functionality. Reevaluation The patient has not gained quadriceps strength like expected. Patient has laxity with varus stress test and is being referred back to MD.

16. Diagnosis 5 Pattern 5F: impaired peripheral nerve integrity and muscle performance associate with peripheral nerve injury She was diagnosed with left weakness and dysfunctions S/P a left TKA with DJD in her right knee. ICD-9-CM Codes 728.87 - muscle weakness-general 719.4 - joint pain-lower leg

17. Prognosis & POC STG To be independent with HEP To have EMG/NCV results by next visit LTG Independent with gym exercise program in 4 weeks To improve knee extension to be -20° in 4-6 weeks Patient Goals Walk without use of assistive device Be completely pain free POC Patient will be seen once/week for 6 weeks and be independent in a gym exercise program ASAP due to being Private Pay Prognosis 5 Patient will demonstrate optimal peripheral nerve integrity and muscle performance over the course of 4-8 months Expected range of visits 12-56

18. Rigor – Intervention 14 Article: Review of 4 recent RCTs since 2009 Initiation: 2 days post-op, sooner the better! Volume: 30 minutes to 4 hours per day Intensity: The higher the better, methods to make pt. comfortable! Adjust to supervised PT: combined modalities may possibly increase improvements Home unit available to decrease costs of PT Home exercises and free gym access while a patient.

19. Patient Education Content: Demonstrated, 1 on 1, pamphlet (NMES), flow sheet, written instructions Pt. instructed on NMES by demonstrating to pt. how to set it up, having the pt. repeat it, and providing written instructions & the pamphlet. Pt’s. concerned addressed at additional visits. Pt. instructed on setting up recumbent bike & using clinic’s equipment with appropriate settings with demonstration & return demo (pt. able to ask available PT if confusion arises) Pt. needed additional help 1 time with knee flexion machine. General anatomy/physiology of condition POC and to maintain the lowest cost Barriers Pt. wears glasses Somewhat quiet (pessimistic?)

20. Patient Education Learning type: did not address patients type (maybe reflective observation?) SPT learning style: Accommodator Cognitive Domain (facts) – recall exercise prescription from flow sheet, where to place electrodes (parameters on HEP), setting up equipment, comparing past PT, establish why exercises were prescribed, plan Affective (attitude) – listening to instruction, participating/informed consent, going through HEP independently, resolve confusing equipment Psychomotor (skills) – observing our demonstration, return demonstrating, practice HEP independently after learning and perfecting it Documentation: use of NMES on location setting and duration and time/day, exercises with times on pt. flow sheet No weight/duration in computer documentation for resistance

21. Strengths & Limitations to Pt. Education Strengths: available to help if confused with equipment, provided instructions to HEP with demo/return demo Weaknesses: Small hand writing (make more legible!), was all of pt’s. concerns addressed?, no written instructions for D/C?

22. Evaluating Clinical Change Goals STG: Pt. to be independent with HEP at next visit (C, EF) Following PT intervention, the pt. will be independent with a HEP and familiar with clinic gym equipment as pt. is private pay and would like to minimize cost. LTG: To improve (R) knee extension AROM to -20° in 4-6 weeks (A, C, EF) Following PT intervention, the pt. will improve (R) knee extension AROM in sitting to -20° to be able to transfer into a car more efficiently. Functional Assessment Not performed but would have wanted to use The Knee Outcome Survey Activities of Daily Living Estimated evaluation score – 27/70 = 38.6% Estimated discharge score – 28/70 = 40%

23. Knee Outcome Survey ADLs 1

24. Knee Outcome Survey ADLs 10 Low SEM (but not the lowest) 73% of subjects score above MDC Large ES and ES SEM (4-5x SEM – indicative of sensitivity) Smaller ceiling effect compared to other functional assessments Missing data? – bad translation InstrumentPre Test (SD)Post Test (SD)SEM (%mean)MDC (%>MDC*)ICC OKS32.5 (7.1)26.1 (9.3)2.2 (7.2)6.1 (60)0.91 WOMAC pain43.5 (20.5)20.4 (18.7)6.8 (15.218.8 (61)0.91 WOMAC stiffness47.4 (23.4)23.5 (21.7)9.8 (28.3)27.1 (51)0.84 WOMAC function39.8 (21.4)20.2 (18.7)4.8 (18.5)13.3 (61)0.96 KOS symptoms17.7 (6.1)23.4 (5.1)1.9 (19)5.3 (60)0.86 KOS function20 (6.7)28.5 (7)1.9 (18.9)5.3 (51)0.93 KOS total53.5 (15.2)74 (15.9)4.1 (8.6)11.4 (73)0.93 SF-12 PC32.7 (7.9)42.1 (9.4)3.5 (10.5)9.7 (55)0.81 SF-12 MC55.2 (10.7)53.1 (9.3)2.9 (6.6)8.0 (56)0.9

25. Values Patient Values Motivation/determinati on Done right quick Hesitant Open to new experiences, revisiting old ones Punctual Social support Cost Personal Ambitious Thorough/complete all tasks Reliable/pleasing everyone Living up to expectations Respect honest Fair Slowing down Humor Understanding Quickly Black & white PT – Professional Goal oriented Efficient Equal tx/professional behavior Being right or confident (knowing all) Teachable Organized Responsible Passion Full effort Flexibility Realistic Little treatment time as possible

26. Johari Window Arena Has general idea of diagnosis, both familiar with functional limitations Exercise program & parameters  written instructions Blind Spot PT knows much more on anatomy of knee, differential dx, expected prognosis, how modalities/exercise affects Share the knowledge! Façade Pt. may not be sharing all possible information as there is so much history, pt. may assume we ask all that is required Home life, kids, environment? Ask all appropriate history questions! Unknown What is truly going on and what potential is there for rehabilitation Refer to another specialist who can shed light on situation

27. Force Field Analysis – Improved ROM Driving Forces Motivated to be normal Doesn’t want to use SPC Free gym use Not a busy schedule/free time? Improve function for family? Therapy instructions/help Restraining Forces Weakness Pain $$$ Weather (winter) Slow progress  Doubt Comorbidities (diabetes, back/neck pain bulge) Anatomical/Physiological knowledge LTG: To improve (R) knee extension AROM to -20° in 4-6 weeks – not met

28. Ethical Issues Private pay – distress Solutions – expensive vs. least expensive Least expensive as pt. does not have the financial resources for extensive PT Pain through exercise – issue Solutions – modalities vs. informed consent vs. referral Informed consent as pt. would have to pay additional for modalities, eventual referral Code of ethics 1, 2, 3, 5, 6 Respect, trustworthy, accountable for judgment, legal/professional obligation, enhance expertise RIPS

29. Evidence Based Practice 20 Functional exercises/outpatient rehabilitation better results compared to traditional/home therapy Benefits did not persist to 12 months Short term rehabilitation focusing on functional exercises! Meta-Analysis3-4 mo (95%CI)12 mo (95%CI) Function (ES)0.33 (0.7 – 0.58)-0.07 (-0.28 – 0.14) Walking (ES)0.27 (-0.13 – 0.67)0.03 (-0.24 – 0.31) ROM (WM)2.9° (0.61° – 5.2°)0.96° (-1.1° – 3°) QoL (ES/WM)1.7 (-1 – 4.3)0.03 (-0.2 – 0.25) StrengthN/A

30. Cost/benefit analysis Patient Private Pay Out of Pocket PTC charges $25/unit (code 00050) Gym free to use during business hours for current patients - $20/mo 1 month after D/C Potential Costs? Commuting TKA revision/other knee? Conduction/genetic testing MD visits Role in society – pt. homemaker and has been living with this condition, overall unchanged Fair service – I believe I would have been satisfied as I’ve seen 2 units cost ~$100 instead DateCost 10/22/13$50 10/25/13$50 11/1/13$50 11/15/13$50 12/4/13$50 Total$250

31. Outcome So far the patient has gained about 15° of knee extension since initial visit and feels she has improved since starting. She has been discharged for now until she gets further testing done on her femoral nerve function to see if she has potential for more rehabilitation. She mentioned she is talking with her physician about doing just a bicompartmental partial knee replacement in her right knee to help with pain, but is very hesitant in doing so after her current TKA dysfunction. Patient working with MD to get genetic testing for HNPP May return to therapy if potential for further gains Looking into brace to provide knee stability preventing joint stress

32. Reflection Examination Did a full evaluation right away Provided functional assessment to evaluate how the patient perceives change Mapped out dermatones – diabetic education? Gathered postop reports Biofeedback? POC Provided more functional exercises & adjust NMES volume Use pain modalities – Pro bono?

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