1. Effects of Balance Interventions on Elderly Patients after TKR Kelsey Shelton VCU DPT 2016

2. 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

3. 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

4. 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

5. 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

6. 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

7. Assessment  Gait  SOB 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 independent  Preform community level functional activity  Attend Sunday sermon

8. 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

9. Interventions  LE strengthening in all positions  Balance activities  Gait training  Manual  Pt education

10. 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

11. 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?

12. 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

13. 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

14. 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

15. 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

16. Liao et al.  Limitations:  Knee OA  Lacked non-intervention control group – result of natural return of muscle/physical function  Dose effect asymmetry  Time lapse

17. Liao et al.  Importance for my patient:  Age  Gender  Knee OA, TKR  Diabetes

18. 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

19. 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

20. 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

21. 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!

22. Effects of Balance Interventions on Elderly Patients after TKR Questions?

23. 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.