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Occupational Therapy and Total Knee Replacements

by Kelly Cowher, MOT, OTR/L

young-woman-doctor-older-man-patient-smiling-1

When facing knee replacement surgery, many clients aren't sure what to expect. While they're looking forward to reducing the extensive pain they've been experiencing and gaining their life back, they aren't entirely sure what to expect during the recovery process. 

Luckily, occupational therapists can play a significant role in helping clients with knee replacements return home and resume normal activities after an acute care stay. Below, we will give you a summary of the important points to address before a client is discharged after having knee replacement surgery.

Evaluation

In some facilities, the occupational therapy evaluation may take place on the day of surgery, known as post-op day zero, or, the day after surgery.

Since the patient still may be groggy from anesthesia or medication, it's important to review the patient's chart and communicate with nursing before starting the evaluation. Be sure to monitor vitals during this session and take extra time before position changes to avoid orthostatic hypotension (the client’s safety is always the first priority; if vitals are unstable, the evaluation can be delayed!).

After a knee replacement, patients will likely be able to bear full weight or as much weight as they can tolerate on their new knee, and there are typically not any formal precautions (although this may depend on facility-specific protocols and physician recommendations). A patient may have a knee brace or bulky dressing - ensure you are having the patient apply the brace per the physician’s order.

The amount of activity that the patient completes during an evaluation depends on their pain levels and activity tolerance at this time. They may get as far as the side of the bed, or they may be able to walk to the bathroom.

At the end of the evaluation, check vitals again and discuss the plan of care with the patient for the rest of their stay. During an evaluation, try to obtain the patient’s home set-up. This way, you will be able to determine if any adaptive equipment/durable medical equipment will be needed before the patient is discharged home.

Pain

All patients experience pain differently. While some patients may experience no pain, others may experience extensive pain on the day of surgery, depending on medications. Be sure to educate patients to stay on top of their pain medication schedules, and modify their therapy schedule if needed. Always remind your patient to keep ice on their knee between therapy sessions to help reduce the overall pain and swelling. 

Activities of Daily Living

The important thing to address when treating a client after any joint replacement surgery is their ADL/ IADL performance and safety upon discharge. The road to recovery is different for everyone, and clients may need to use compensatory strategies during ADLs depending on the range of motion of their knee.

Is the client able to bend at their waist to don and doff pants, socks, and shoes, or will they need to use a compensatory strategy such as resting their thigh on the bed during lower body dressing?

Maybe they will need equipment such as a reacher or a sock-aid to complete the task independently. In the rare event that the client is discharged home with a catheter, you will need to provide education on threading the catheter through the pant leg first.

Also, if the patient is discharged with a knee immobilizer and ROM restrictions, dressing using adaptive equipment while long sitting in bed may be the safest option.

Compression stockings are another challenge. If a client is having difficulty donning regular socks, having a family member assist with compression stockings is best (if possible). If a family member is not available, the client can use a rigid sock-aid to start the stockings over their toes. Another method is turning the stocking halfway inside out, stretching it as much as possible, then starting it over the toes.

Functional Transfers

Another key piece of occupational therapy treatment is the performance of safe functional transfers. Is the client able to sit down and stand up from the commode without assistance? A toilet riser may be needed upon discharge for the patient’s commode at home. Will the client be able to raise their leg to step into the bathtub or over the threshold of the shower?

Be sure to check with the doctor about advising patients when to shower, as this process can change depending on the type of wound dressing they have. For safety, a shower seat, transfer tub/bench, and/or grab bar may be recommended. 
Transfer tub benches are helpful if the patient has a tub shower (as long as there is enough space in the client’s bathroom and the shower has curtains, not doors). With a tub bench, the client can easily back up to the seat, then lift their legs into the tub while seated, rather than standing. If your patient is interested in this option, be sure to know where to recommend locations where this equipment can be obtained/purchased. To prepare for this home set-up, have the client practice getting in and out of bed on the side they normally would at home, with the head of the bed flat and bedrails down.

If a client is having difficulty with bed mobility, a leg lifter or bed cane may be recommended. Be sure to teach the client the correct use of the leg lifter and emphasize maintaining proper alignment of the leg.

Car transfers can be simulated by using a transfer tub bench if one is available in your facility. Trash can be turned on its side is one idea that can be used to simulate the car door threshold.

Discharge Planning

Luckily, acute care stays following knee replacements typically only last 1-2 days. so discharge planning can start during the initial evaluation. If possible, have the client's family or caregiver present during therapy sessions, so they are aware of how much assistance the patient will need upon discharge, and be able to make the necessary home modifications for a seamless transition. 

If a client is having difficulty using the stairs in physical therapy, discussing a temporary first-floor set-up with the client and family may be necessary. In this case, you may need to recommend a bedside commode, and the patient’s willingness to sponge-bathe if a bathtub is not available on the first floor. You will also have to discuss walker safety with the client (e.g. not carrying items while pushing a walker). Walker bags or trays can help with this.

There are cases where clients will be returning home alone and will have little to no assistance available. Occasionally, these clients may opt to go to a skilled nursing facility for a few days to receive additional therapy before returning home. If they are returning home alone, you may need to address light meal prep and housekeeping strategies. These are all things to be discussed throughout the client’s stay.

“Interdisciplinary communication is key; social workers and case managers are very good about managing the client’s insurance information and communicating the discharge plans with the client’s family.”

Conclusion

There are a lot of important points to address before a client is discharged after having knee replacement surgery. From pain management to proper home setup and independence, occupational therapists can help clients and their families to ensure a safe discharge home.

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