Chapter 28 and 29

1. Chapter 28 and 29 Post Surgical Rehabilitation

2. Overview • Although many musculoskeletal conditions can be treated conservatively, surgical intervention is often indicated in cases where a sufficient traumatic or degenerative injury has occurred.

3. Overview • The typical criteria for surgical intervention includes: • A failure to respond to a 4-6 month course of conservative measures • Severe levels of pain that significantly limit the performance of daily activities and personal care • Gross joint instability and abnormal joint alignment with accompanying loss of function

4. Surgical complications • Some of the more serious post-surgical complications include: • Infection • Deep vein thrombosis • Pulmonary embolus • Poor wound healing • Excessive scarring and adhesion formation

5. Surgical procedures • The proposed advantages of arthroscopic procedures over the traditional open procedures include: • Smaller skin incisions • More complete inspection and access of the surgery site • The ability to treat intra-articular lesions • Less soft-tissue dissection

6. Post-surgical Examination • History and Systems Review • Details about the type of procedure performed are noted, as well as the location, nature and behavior of symptoms. • The clinician asks about the patient’s current and previous functional status, and discusses with the patient, what their functional goals and predicted outcomes are • The clinician should determine whether any circulatory and pulmonary complications exist such as thrombophlebitis, pulmonary embolus, or pneumonia.

7. Post-surgical Examination • Pain • The patient’s pain level is recorded on a visual analog scale • Integumentary integrity • The clinician should observe and palpate the incision, check the integrity and mobility of the scar, and determine if the degree of edema, crepitus, and tenderness is appropriate. Abnormal redness, swelling, or increased heat could indicate an infection, especially if accompanied with a fever.

8. Post-surgical Examination • Range of motion (ROM) • The range of motion of the involved extremity can be assessed • Where possible and appropriate, the ROM is assessed actively. Otherwise the clinician assesses the available passive range of motion, taking care to not over stress the healing structures.

9. Post-surgical Examination • Joint integrity and mobility • A general examination of the healing area is performed checking the musculature, the tendons and the ligaments where appropriate. • Muscle performance • Resisted testing can be performed on the muscles of the upper and lower extremities that are not directly related to the surgery site • The clinician examines the patient’s ability to perform isometric exercises pertinent to the post-surgical protocol.

10. Post-surgical Examination • Function • The clinician should determine the patient’s level of functional independence, noting which functional tasks (transfers, bed mobility, and ambulation) the patient is able to perform independently • The patient should be provided with a safe and efficient means of ambulation where appropriate

11. Post-surgical Rehabilitation • Amongst the key factors that must be considered in the post-surgical rehabilitation are: • The patient’s age • The patient’s physical status, including weight, and other medical conditions such as any history of cardiovascular or peripheral vascular disease, or diabetes • Social lifestyle of the patient • Pre-operative joint contracture or muscle atrophy • Type of surgery • Method of fixation • Surrounding soft tissues involved • Degree of correction of biomechanical alignment • Functional and recreational goals of the patient

12. Post-surgical Rehabilitation • Acute phase goals: • Control pain and inflammation • Allow healing progression of surgical site and help prevent complications • Retard muscle atrophy and enhance dynamic stability • Minimize detrimental effects of immobilization • Patient compliance with post-surgical restrictions • Initiate restoration of range of motion

13. Post-surgical Rehabilitation • Exercise hierarchy • PROM • AAROM • AROM • Sub-maximal isometrics in pain-free ranges • Sub-maximal isometrics throughout available range • Progressive resisted exercise

14. Post-surgical Rehabilitation • Restore, maintain, or improve patient’s cardiovascular status • Use the extremities unaffected by the surgical procedure

15. Post-surgical Rehabilitation • Maintain range of motion and fitness of the kinetic chain and remainder of the body without detriment to the healing of the surgical site

16. Post-surgical Rehabilitation • Ensure patient safety and independence • Assistive devices • Family support • Home exercise program

17. Post-surgical Rehabilitation • Functional phase goals • Attain full range of pain free motion • Restore normal joint kinematics • Improve muscle strength to within normal limits • Improve neuromuscular control • Restore normal muscle force couple relationships