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Total Joint Rehab . . . A Functional Approach

Most people who experience joint dysfunction over time don’t just lose mobility in a single joint; they lose entire patterns of movement. A person with an unstable knee or painful hip gradually stops squatting, bending, and rotating. He or she may lose vestibular and peripheral balance responses due to lack of use. Compensatory movement patterns eventually replace normal movement, which can cause undo stress to otherwise healthy joints. By the time a patient presents for joint replacement surgery, multiple movement patterns and functional abilities have been adversely affected.

A shift in traditional thinking has led many physical therapists to consider the needs of their joint replacement patients more holistically. In the not too distant past, physical therapists used the hash marks on the goniometer and the distance a patient could ambulate with a single point cane as indicators of successful joint replacement surgery. With fewer healthcare dollars and increased comorbidities, physical therapists now need to integrate bodies of knowledge across orthopedic, neurological, respiratory, and circulatory systems and break away from the conventional approaches that targeted the optimization of movement of a single joint in a cardinal plane.

Optimal outcomes following single joint arthroplasty are rarely limited to the pain, range of motion, and integrity of a single joint. In fact, the buzzword “outcomes” means different things to different people. Positive outcomes for the engaged consumer have mushroomed to include nebulous measures like quality of life, resumption of activities, and a rehabilitative course that matches his or her expectations. The healthcare industry, including payers like Medicare and private insurance companies, consider complication-free procedures, timely discharges, and low re-hospitalization rates to be the benchmarks for success.

Such are the challenges of the new-age physical therapist specializing in joint replacement surgery.

Gone are the days of lengthy hospital stays- where in-bed exercises consisting of feeble ankle pumps and gentle heel slides dominated the first few physical therapy visits following a hip or knee replacement. Gone, also, are the seven page home exercise programs, neatly assembled by the therapist and ultimately ignored by the patient whose only desire is to get back to walking. Shorter hospital stays and pressure for quicker outcomes translate into immediate out of bed and weight bearing physical therapy protocols.

The optimal exercise program, the one that offers the greatest bang for the buck, consists of closed chain, multi-joint, functional movement patterns performed in standing. Instead of passively stretching a tight calf in bed, adequate calf stretch can be achieved in standing, with the body weight shifted onto the foot and the knee dropped slightly forward. This simple stretching pose also provides trunk stabilization, hip and knee control, proprioceptive and somatosensory feedback, bowel motility, cardiovascular training, and pneumonia prevention. A simple head turn during a sit to stand exercise engages the vestibular system. Three or four standing, weight-bearing exercises can accelerate the rehab process, largely by improving the general health of the body’s systems, improving compliance with home exercises that promote function, and optimally recruiting more motor units with the closed chain.

In today’s healthcare environment, physical therapists are being pressured for better and quicker results with their joint replacement patients. The fitness industry has been employing these techniques with growing popularity- as seen in sledge hammer swinging, shovel scooping, and overhead heaving movement patterns dominating the curriculum of warehouse fitness clubs. The diverse definition of “outcomes” among decision-makers, limited healthcare dollars, and an increase in medically complex patients receiving joint replacement surgery requires physical therapists to produce excellent results in shorter timeframes. Functional movement patterns may be the secret sauce.

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