Post on 12-Feb-2022
1
Anil Bhave, PTDirector Gait LaboratoryClinical Director Orthopedic RehabilitationRubin Institute of Advanced OrthopedicsSinai Hospital, Baltimore, Maryland
Muscle Activation deficitsAthrogenic muscle inhibition
(AMI)
• What is AMI and what causes it?
Bhave 2017
Simple formula
Bhave 2017
Quadriceps Arthrogenic Muscle Inhibition:Neural Mechanisms and Treatment PerspectivesDavid Andrew Rice, BHSc,* and Peter John McNair, PhD†
Conclusions: AMI remains a significant barrier to effective rehabilitation in patients with arthritis and following knee injury and surgery. Gaining a better understanding of AMI’s underlying mechanisms will allow the development of improved therapeutic strategies, enhancing the rehabilitation of patients with knee joint pathology.
Arthrogenic muscle Inhibition
• Pain
• Joint effusion
• Age (Central activation deficit)
• Instability
• Habitual Limp leads to quads avoidance gait
Bhave 2017Bhave 2017
2
CAR (Central Activation Ratio)Age related
Bhave 2017
Mechanisms Undlerlying Quadriceps Weakness in KneeOsteoarthritisSTEPHANIE C. PETTERSON1,2, PETER BARRANCE3, THOMAS BUCHANAN4, STUARTBINDER-MACLEOD2, and LYNN SNYDER-MACKLER
Med Sci Sports March 2008
Bhave 2017
Habitual limp
Bhave 2017 Bhave 2017
Knee Flexion Lever Arm
Bhave 2017
3
What about touniquet?
Bhave 2017
EMG changes in 18/25 patients post menisectomy
• EMG changes temporary
• 16/18 resolved in 6 months
• Direct correlation exists between EMG abnormality and duration of tourniquet inflation and patient’s recovery time
Bhave 2017
Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A
Randomized Trial.Dennis DA1, Kittelson AJ, Yang CC, Miner TM, Kim
RH, Stevens-Lapsley JE.
• Quad weakness 11.3 Nm for 3 months
• No effect on hamstrings
• Small difference in blood loss
Bhave 2017
Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty.
Liu D1, Graham D2, Gillies K3, Gillies RM4.Knee Surg Relat Res. 2014 Dec;26(4):207-13. doi:
10.5792/ksrr.2014.26.4.207. Epub 2014 Dec 2
• Increased pain in tourniquet group
• No difference in ROM, strength, Oxford Knee score
• Quad strength compromised up to 6 months as studied by surface EMG
Bhave 2017
Bottom line about tourniquet?
• More than 2 hours
• Max optimal pneumatic pressure 270 to 290 mm/hg
Bhave 2017
What are the long term effects of AMI
Bhave 2017
4
Bhave 2017
Functional problems after TKA
Bhave 2017
Quadriceps strength 98 OA (55 to 72 yrs.) compared to Fearon F (1989) data on 79
asymptomatic patients
0
10
20
30
40
50
60
70
Male OA Malenormal
Female OA Femalenormal
Male OA
Male normal
Female OA
Female normal
(Force/BW)*100Bhave 2017
Difficulty in post TKA patients ( 661 patients 1‐4 year f/u
% of patients with difficulty
Limp or difficulty in gait 53%
Difficulty with stairs 54%
Difficulty getting out of car 38%
Difficulty getting out of chair 31%
Difficulty in participating in recreational activity 50%
Stiffness and pain 41%
Clin Orthop Relat Res. 2014 Jan;472(1):133-7.
High level of residual symptoms in young patients after total knee arthroplasty.Parvizi J, Nunley RM, Berend KR, Lombardi AV Jr, Ruh EL, Clohisy JC, Hamilton WG, Della Valle CJ, Barrack R
Need for prehabilitation and rehabilitation in TKA
Bhave 2017
Bhave 2017
The Effect of a Prehabilitation Exercise Program on Quadriceps Strength for Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Pilot StudyCarly McKay, PhD, Harry Prapavessis, PhD, Timothy Doherty, PhDAmerican Academy of Physical Medicine and Rehabilitation1934‐1482/12/$36.00 Vol. 4, 647‐656, September 2012
Brace patients
0
0.5
1
1.5
2
2.5
1 2 3 4
Brace and NMESCohort
5
Use of Extension assist brace post TKA
Bhave 2017
NMES How strong
Maximally tolerated
Bhave 2017
Physical Therapist
•Can we be Masters of Disasters?
Bhave 2017
Need to innovate
because routine did not work well
Bhave 2017
Case 1
Arthrogenic muscle inhibition with ROM
deficit
June 2013
Bhave 2017
6
PCL, LCL,MCL complete and partial ACL rupture
Bhave 2017
Post reconstruction Infection
August 2013
Bhave 2017
Post Infection contracture
December 2013
Bhave 2017
Bracing and Therapy protocol
• EXT guardian brace all day long
• Removable extension splint all night
• PT 1-2 times a week
• NMES at home 2 times day in bed
• Hip strengthening in brace
• WALKING in guardian brace two crutches to one crutch to no device
Bhave 2017
Bhave 2017 Bhave 2017
7
Bhave 2017 Bhave 2017
CKD +Sport EXT
February 2014Bhave 2017
Full extension
Bhave 2017
PT ROM Progress
Bhave 2017 Bhave 2017
8
Transitioned to Guardian sports brace and
Sports specific PT
Bhave 2017
PT progress
May 2014
Bhave 2017
Bhave 2017
Return to non contact sports
Bhave 2017
Sports specific perfomance
• Strength equal to the opposite side (Isokinetic testing)
• Single hop for distance with in 5 cms of normal
• Full ROM• Lateral jump equal to opposite
side Bhave 2017
Return to non contact sports
Bhave 2017
9
Case 2 Valgus knee deformity
beware of peroneal nerve
Bhave 2017 Bhave 2017
Bhave 2017 Bhave 2017
Bhave 2017
Post CKD and PT
Bhave 2017
10
Bhave 2017
Happy Patient
Bhave 2017
Bhave 2017
Case 4Congenital Knee flexion
contracture
Bhave 2013Bhave 2017
Custom solution
Bhave 2017
Improved Gait
Bhave 2017
11
Bhave 2017 Bhave 2017
Bhave 2017 Bhave 2017
Case 5: Knee Flexion Contracturewith Grade 2 Quads
Bhave 2017
Initial Rx
• BoNT –A , Hamstrings.
• Serial casting 1 week X 2.
• PT started 2 times a week after serial cast removal.
• Home NMES Unit
• Once a week TDN/IMT
• Walking brace fitting 2 weeks after PT start.
Bhave 2017
12
Initial brace fitting400 KFC, 350 Quad Lag
Bhave 2017
Patient with 25° of knee flexion contracture andGrade 3- quadriceps strength with 40°active extension lag
Bhave 2017
Patient with 15° of Knee flexion contracture andGrade 3- quadriceps strength with 40° active extension lag
Bhave 2017 Bhave 2017
Thank You
anilbhave@yahoo.comabhave@lifebridgehealth.org
Bhave 2017