Clinical Problem Solving I: Case Presentation FALL 2016 Jake Hillyard

Clinical Details and Patient Intro Clinical experience at a local Acute Care Hospital spending majority of time on Orthopedic Floor 63 yr. old male Lives in 2 story home with stairs to 1st floor and 1 handrailing Progressive Knee Osteoarthritis and Meniscal damage Elective R Total Knee Replacement Pertinent PMH: Bronchitis, R Meniscal Repair, Knee Arthroscopy, Hx of DVT No serious comorbidities

History of Injury Patient experienced a fall at work in 2010 Diagnosed with Meniscal tear and microfractures on femoral condyles Participated in conservative Physical Therapy to manage meniscal tear and progressive knee OA with little reported effect Underwent meniscal repair with no difference in pain and arthroscopy Dec 2014 and Jan 2016 Pain escalated to a need for surgery

Prior Patient Activity Level Patient lived a HIGHLY active lifestyle for many years Played semi-professional soccer in ‘70’s Began cycling in an effort to save his knees Joined the high mileage cycling crowd and in the 90’s cycled over 7,300 miles in one calendar year. Averages to 20 miles a day. Patient reported exercising regularly prior to surgery

Initial Evaluation post op day 1 ROM: Good AROM throughout with exception of R knee due to dressing thickness and lack of muscle control R Knee ROM not officially measured with goniometer Strength: 5/5 MMT throughout but R knee not tested. Patient demonstrated a lack of R knee strength in weight bearing and showed a propensity to buckle when not focused on activity. Sensation: Decreased in RLE

Initial Evaluation post op day 1 cont’d. Transfers: Independent with exception of sit-to-stand and stand-to-sit which required contact guarding Gait: 180 ft. with rolling walker and demonstrated step to pattern with rolling walker and exhibited decreased knee flexion during swing Vital Signs were normal prior to and throughout eval Motivated and eager to improve Total Joint Hospital Guidelines: 25 ft.

ICF Model Impairments Participation Restrictions Activity Limitations Pain Decreased Knee ROM Decreased Quad control Decreased knee flexion during swing Participation Restrictions Activity Limitations Unable to teach at technical college Abnormal gait due to pain Altered social life with gait distance limitation Unable to sit for extended periods Unable to sleep continuously

Treatment Plan Gait training – with rolling walker Stairs training – utilizing 1 handrail only LE exercises: Quad Sets (R) x 10 Ankle Pumps (Bil) x15 Heel Slides (R) x 10 Sitting Knee Flex/Ext (R) x 10

Treatment Goals At Discharge, patient will be able to: Ambulate 200 ft. with rolling walker and contact guard Achieve 90° of knee flexion Negotiate 5 steps with 1 railing with stand by assist

Treatment post op day 2 Gait Training: Ambulated 180 ft. demonstrated step through pattern with rolling walker Stairs Training: Negotiated 10 steps utilizing 1 hand railing with stand- by assist LE Exercises: Patient’s vitals remained normal throughout treatment and showed little to no fatigue Total Joint Hospital Guidelines: 50 ft. Quad Sets (R) x 10 Ankle Pumps (Bil) x15 Heel Slides (R) x 10 Sitting Knee Flex/Ext (R) x 10

Treatment post op day 3 Never actually took place Doctor decided to discharge patient early based upon patient’s high gait ability and endurance and ability to negotiate stairs Goal of measuring 90° not achieved due to discharge

Clinical Question For a 63-year-old male preparing for a TKA, is greater lower extremity strength predictive of better functional outcome measures following a TKA surgery? Hypothesis: Yes, I predict that greater lower extremity strength will improve functional outcome measures following a TKA surgery.

Article #1 Prognostic Factors for Functional Outcome of Total Knee Replacement: A Prospective Study Sharma L., Sinacore J., Daugherty C., Keusis D., Stulberg D., Lewis M., Baumann G., Chang R. Published in the Journal of Gerontology: Medical Sciences 1996. Vol. 51A No.4. M152-M157

Study Details Prospective Cohort Study (N = 47) Goal was to determine the relationship between prognostic factors and functional outcomes assessed 3 months after surgery Prognostic Factors: Baseline Physical Functioning Baseline Psychological Functioning Baseline Social Functioning Gender Other Medical and Demographic Variables

Data Compilation – 1 month pre, 3 months post Short Form 36 (0-100) Physical Functioning Social Functioning Psychological Functioning Self Motivation Inventory (SMI) Bodily Pain Mental Health Role Functioning (emotional) Cumulative Illness Rating Scale Quadriceps/Hamstrings Strength Cybex Isokinetic Dynamometer Mid-range Mean of 3 attempts

Conclusions/Limitations Lower Extremity Strength was not seen to be a strong predictor of functional outcome measures. Rather improvements were attributed largely to psychosocial factors. Study Limitations Small Sample Size Use of 1 clinic to make large generalizations Age of Study (1996)

Article #2 Preoperative Quadriceps Strength Predicts Functional Ability One Year After Total Knee Arthroplasty Mizner R., Petterson S., Stevens J., Axe M., Snyder-Mackler L. Published by The Journal of Rheumatology 2005 32(8): 1533-1539

Study Details Prospective Cohort Study (N = 40) Goal was to determine the predictive value of preoperative quadriceps strength on functional performance 1 year post surgery Outcomes Measured Quadriceps Strength Knee ROM TUG and SCT SF36 KOS-ADLS Pain (from SF36)

Data Compilation – 2 weeks pre, 12 months post Quadriceps Strength Timed Up and Go (TUG) Isometric in electromechanical dynamometer Stair Climbing Test (SCT) Hip flexed 90°, knee flexed to 75° Superimposed E-Stim to ensure max Force produced normalized by BMI Short Form 36 Knee ROM Knee Outcome Survey/Activities of Daily Living Scale (KOS-ADLS) Flexion and Extension measured with standard goniometer

Conclusions/Limitations Quadriceps strength was determined to be a strong predictor of functional performance on the TUG and SCT, but not on the self- reported functional questionnaires 1 year after TKA. Study Limitations: Measurements taken at 1 year only Small Sample Size Higher % of men Pain Assessment not specific to Knee

Final Conclusions Lower extremity strength may have predictive value for patients undergoing a Total Knee Arthroplasty, especially with regards to functional tasks such as climbing stairs and moving throughout the home or community. More research with larger sample sizes and more frequent data collection points is needed to add to the predictive value of lower extremity strength.

Back to my patient… Good Prognosis. Limitations: Positives: No official outcome measures utilized prior to surgery No official muscle strength measurements prior to surgery Positives: Previous activity level Early discharge High gait distance/endurance High relative motivation and drive Good Prognosis.

Questions?