Effects of Balance
Interventions on Elderly
Patients after TKR
Kelsey Shelton
VCU DPT 2016
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
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
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
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
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
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
 Return
to home independent
 Preform
 Attend
Restrictions
community level functional activity
Sunday sermon
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
Interventions
 LE
strengthening in all positions
 Balance
 Gait
activities
training
 Manual
 Pt
education
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
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?
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
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
 Stair
test
climbing test
 Timed
10m walk
 TUG
 WOMAC
Index
Osteoarthritis
Liao et al.
Interventions
3x per week, one on one with PT

Training Routine (60 min)
 Warm-up
 Stretch
 Mobility
 Muscle
exercises
strengthening
 Functional
task
oriented exercises

Balance (90 min)
 Side
stepping, braiding,
tandem walk, change
direction, airex, BAPS,
balance beam
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
Liao et al.

Limitations:
 Knee
OA
 Lacked
non-intervention control group – result of natural
return of muscle/physical function
 Dose
effect asymmetry
 Time
lapse
Liao et al.

Importance for my patient:
 Age
 Gender
 Knee
OA, TKR
 Diabetes
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
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
Liao et al.

Limitations
 Same
authors and population
 Specific
 Lack

surgeon
of definition
Importance to my patient
 Effect
on long term therapy
 Incorporation
into POC
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!
Effects of Balance
Interventions on Elderly
Patients after TKR
Questions?
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.