TKR Protocol

Steps Performed In First Week 1. Ankle pumps Report/ Comments Move your foot up and down by using calf muscles and shin muscles. To prevent DVT and improve circulation to LE. 20 reps of 3 sets, 5 times a day Regain at least 70 degrees of passive and active range of motion in the knee to perform sit to stand transfers with minimal compensatory activity. 1. Straight Leg Raise: Lift your leg toward the ceiling up to 45 degree while keeping your knee straight. Bend the opposite knee for support. 2 sets of 10reps, 3 times a day 2. Hip Outward and Inward: Move your leg out to the side and then back, keeping your knee straight and toes pointed toward the ceiling. 2 sets of 10reps, 3 times a day 3. Hip Rotation: Roll your leg in toward your other leg and then back out. 2 sets of 10reps, 3 times a day 4. Heel slides: Slide your heel towards your buttocks. Keep your heel on the bed. Do not go beyond 70 degree. 2 sets of 10reps, 3 times a day Maintain the muscle strength up to 3/5-4/5. 1. Quad Sets: Lie on your back with your legs straight and toes pointed toward the ceiling. Put a towel under the operated knee and Tighten your thigh or upper leg muscles. Hold for 5-10 seconds and then release. Do it 5-10 times, thrice a day. 2. Glutei sets: Tighten your buttock muscle and hold for a count of 5 seconds. Repeat five to ten times, three to four times each day. 3. Hip adductors isometrics: While lying/sitting, squeeze a rubber ball between your knees. Hold the squeeze for 5 to 10 seconds. Do the exercise 5 to 10 times, thrice a day (If you don't have a ball, put your hands or fists or towel between your knees and then squeeze it). 4. Hamstrings sets: Tighten the muscle on the back of your operated thigh by pressing your heel of operated side into the towel. Hold for 5-10 seconds and then release. Do it 5-10 times, thrice a day Alerts

2. Active/active assisted/passive (A/AA/PROM) exercises

3. Isometric exercises

4. Patellar mobilization

5. Stretching exercise

6. Ambulation with walker

To decrease the adhesions around knee joint. And, to increase the ROM. This involves moving the patella, or knee cap in two direction i. e. medial and lateral. While sitting in the bed with knee extended and leg completely relaxed, take the patella between your thumb and index finger, and slowly and gently move in both directions. Do the 3 sets of 10-15 reps, twice a day. To decrease tightness 1. Hamstrings Stretch: Lay on your back Stretch one leg out in front of you on the floor Pick up your opposite leg and lift upwards, keeping your knee straight and your toes pointed away from your face. Hold 30 sec then repeat on opposite side. Do it 3-5 times, twice a day. 2. Adductors Stretch: Cradle the leg by placing your hand under your knee and holding it. Place the other hand under the heel, or on the hip, to stabilize the hip joint. Keeping your knee straight, move the leg along the surface of the bed, toward you and away from the other leg, to approximately 45 degrees. Then bring the leg back to the other leg. Do it 3-5 times, twice a day. 3. Calf Muscle Stretch: Place one hand on the knee to prevent it from bending. Your other hand cups or cradles the heel and your forearm is placed against the ball of the foot. Push the ball of the foot forward, bending the foot toward the knee and stretching the muscles in the back of the leg. Ambulation at least 100 feet with appropriate assistive device. Stand up tall and look ahead while you walk. Move the walker or crutches forward rst, followed by your operated leg. Then move your unaected leg forward. Put your weight on the walker or crutches to take the weight o your operated leg when you step onto it. Follow your own weight bearing instructions when using a

walker or crutches. 7. Transfer training To make independent in transfers. From bedchair & bedtoilet chair. For 10-15 min, 3-5 times a day.

8. Cryotherapy

9. Deep breathing exercises

For improving lung functioning and reduce chest complication.

In 2ndWeek 1. Active/active assisted/passive (A/AA/PROM) exercises (seated and supine) as indicated. 2. Standing closed chain terminal knee extension with light band above knee

Increase range upto 90 degree flexion. Same as previously indicated according to condition of the patient.

3. Isometric exercises. 4. Strengthening exercises like resisted ROM, wall slides

5. Patella femoral and tibial femoral joint mobilization as indicated

For the final 15 degrees of knee extension. Starting position is hips externally rotated 30 to 45 deg (10 oclock and 2 oclock) and feet apart so that the medial malleolus is in line with the greater trochanter of the femur. One end of physical therapy band is securely attached to a fixed piece of equipment or wall mount, while the other end is securely attached around the knee joint. The knee is flexed to 30 deg and then returned to between 0 to 5 deg flexion. Start at 3 sets of 8 reps and progress to 4 sets of 8 reps. If required, do Isometric exercises of quadriceps, hamstrings, gluteal and adductors. Wall slides: Stand upright with your back against a wall and feet shoulder-width apart. Slowly bend your knees, sliding your back down the wall for a count of five until your knees are bent at a 45-degree angle. (Do not bend too much further than this, as it will cause increased strain on your knees.) Hold this position for 5 seconds. Begin straightening your knees for a count of five, sliding up the wall until you are fully upright with your knees straight. Repeat five more times per set twice a day. Femorotibial joint mobilization: - Patient is positioned in prone with thigh fixated to table via use of a stabilizing belt. The therapist grasps the involved leg just proximal to the malleoli and provides a distraction force by leaning backward along the line of the tibia. This technique is particularly effective for pain control; other positions may be more beneficial for higher-grade mobs to increase general joint play and flexion. An alternative position is performed with the patient sitting with leg hanging off a table.

Anterior Glide: Anterior tibial glides can be performed several ways, but it is often (and most functionally) performed with the patient supine and lower leg propped, reaching maximal or near-maximal extension. The proximal tibia is stabilized with one hand and the mobilizing hand is placed on the distal femur. A posteriorallydirected force is applied directly downward through the distal femur. This mobilization is useful for helping to gain joint play necessary for obtaining terminal extension, particularly when a patient only lacks a few degrees to reach full extension. Posterior Glide: Patient is positioned in supine with the knee slightly flexed and a prop placed under the distal femur. The stabilizing hand is used to prop the distal femur and the mobilizing hand is placed over the proximal tibia just below the tibial tuberosity. The mobilization itself is performed by a force perpendicular to the line of the tibia. This technique is useful for obtaining joint play necessary for knee flexion. Although this technique is often used in the closed-packed position, it can also be performed with the knee flexed near the level of restriction, similar in position to the posterior drawer test for the PCL. Rotational Glides: Internal and external rotation glides are useful for gaining joint play for knee flexion and extension, respectively. These glides can be performed at various points in the normal ROM of the knee with the patient positioned in supine. The stabilizing hand grasps the distal femur and the mobilizing hand grasps the heel of the patient's foot. The ankle is maximally dorsiflexed so that rotational motion is applied to the rotating tibia and not at other joints more distally. The foot is either rotated medially or laterally, depending on the mobilization preferred (internal or external rotation) and at the range where restriction may be apparent.

6. Neuromuscular electrical For quads if poor quad contraction is present, then stimulation (NMES) apply NMES for 15-20 min/session. 7. Gait training To improve function and quality of involved limb performance during swing through and stance phase. 8. Cryotherapy If required. 9. Static cycle (initially To increase knee joint mobility. partial revolution then full revolution), no resist. 10. Stair Climbing To go up the stairs: Keep the cane/crutches with the operated leg. Start close to the bottom step, and push down through your hands. Step up to rst step, the non-operated leg goes up rst. Step up to the same step with the operated leg and crutches, putting only the advised amount of weight through your operated leg. To go down stairs: Start at the edge of the step. Bring the cane/crutches and your operated leg down to the next step. Use upper body strength to support your weight and keep your balance. Step down to the same step with the nonoperated leg, putting only the advised amount of weight through your operated leg. Check your balance each time before proceeding to the next step.

In 3-6 week 1. Resisted Rom exercises

2. Prone knee flexion ROM assisted with belt / opposite leg / manually. 3. Short Arc Quads/ Long To increase quad strength Arc Quads Short Arc Quads Lay on your back and place a ball/pillow under your affected knee Keeping the back of your knee on the ball/pillow straighten your knee Return to starting position and repeat it 10 times for 3 sets twice a day. Long Arc Quads While sitting in a chair extend your affected knee as high as comfortable and return to starting position Keep your trunk straight, avoiding leaning back Repeat it 10 times for 3 sets twice a day. 4. Scar and soft tissue It Diminishes swelling and inflammation massage to quadriceps and hamstrings as needed 5. Patella femoral and tibiofemoral joint mobilization as indicated 6. Mini squat Achieve Range upto 110-115 degree. - As described previously.

Muscle strength 4/5-5/5. - Resistance applied through manually or by thera band while performing active resisted ROM exercises.3 sets of 10-15 reps, twice a day. To increase hams strength

To increase quad strength. - Holding on to chair or walker hold 2-3 seconds at 30 flexion 7. Wall squats To increase quad strength. - Make sure knee does not twist or pass toes (begin 0-30, progress to 0-45 and then eventually 0-60 degrees as long as no complains of knee or patello-femoral pain 8. Initiate walking program To improve gait pattern with normal pattern with 1 crutch or cane 9. Continue NMES of If required. quads if poor muscular performance of quad is present 10. Continue stretches, as indicated

11. Continue stationary - Progress to resistance training from active bicycle for ROM cycling. 12. Proprioceptive training To improve static and dynamic balance. such as weight shifting, Proprioceptive training such as weight tandem walking, lateral shifting, tandem walking, lateral stepping stepping over/around over/around objects, obstacle courses, & objects, obstacle courses, lower extremity proprioceptive & lower extremity neuromuscular facilitation (PNF). proprioceptive Lower Extremity PNF: neuromuscular Diagonal 1: Hip Flexion, Adduction, facilitation (PNF). External Rotation; Knee extended; Foot Dorsi-Flexion (D1 Flexion) and Hip Extension, Abduction, Internal Rotation; Knee Extension; Foot Planter Flexion (D2 Extension). Diagonal 2: Hip Flexion, Abduction, External Rotation; Knee Extension; Foot Planter Flexion (D2 Flexion) and Hip Extension, Adduction, Internal Rotation; Knee Extension; Foot Dorsi-Flexion (D2 Extension). 13. Stair Climbing After 4-5 weeks stair climbing with the help of sticks and railing. - Initiate with 4-5 steps and improve day by day.