A Case Report of Nerve Damage and Knee Extensor Weakness as a Result of a TKA - PowerPoint Presentation

Slide1

A Case Report of Nerve Damage and Knee Extensor Weakness as a Result of a TKA

Robert Whittaker, SPT

University of North Dakota

Slide2

Patient Presentation

49

y.o

. female with (L) TKA in 2009 who suffered a fibular nerve palsy as well as having the quads “shut down”

Patient evaluated on 10/20/13 for posterior knee pain & discharged on 12/9/13 for a total of 5 visits.

Patient private pay & had 20 independent visits to clinic gym

Pt. instructed on home NMES use & to use clinic’s gym to recumbent bike, leg press/extension/curls with emphasis on eccentric contraction for duration of rehab.

Pt. progressed from lacking 50° of AROM (L) knee extension to lacking ~35° with some improvement in pain.

Referred

to physician for genetic testing for nerve disease & nerve conduction test of femoral nerve (HNPP?).

Pt. stated she was looking

into getting a

knee brace.

Slide3

Clinical Decision Making

Slide4

Patient Care

Accept

Familiar with TKAs and protocols, treatment appropriate for pt. to regain strength

Skills to improve quadriceps weakness, seen multiple TKAs in

clinicals

Direct

Goals, extent of condition, patients availability, handling techniques

Indirect

Private pay, travel in winter, can do HEP, pain, past therapy, PMH, life

Refer

Refer back to MD eventually from little progress

Slide5

History

Patient is full time homemaker (military wife?)

C/O constant (L) posterior

knee

pain 5/10

Patient has to lift her leg into car and leg gives out often

Pain and weakness in left leg cause her to ambulate with SPC

(R) knee pain secondary to DJD and hasn’t walked well for

years

Pt. wore an AFO to ambulate after TKA but no longer wears

Also has neck & low back pain due to bulging

discs

Indicated she has diabetes, thyroid trouble, arthritis, sleeping problems, frequent headaches, & degenerative joint disease for many years

Many imaging studies (none available)

Slide6

Pain Drawing

Slide7

History Cont’d

Medications: Aspirin (81mg), Inderal (120mg),

Janumet

XR-50/100xz), Lipitor (20mg), Lisinopril (40mg), Omeprazole (20mg),

Synthroid

(50mcg), Topamax (100mg),

Zyrtec

(10mg)

Allergy Meds: Penicillin, Ampicillin, Bactrim,

Celocin

,

Feldene

,

Zomig

Family

history:

Her father had a myocardial infarction (MI) as well as COPD. Her mother has

prediabetes

. Both her parents have high blood pressure

.

Slide8

Past Medical History

Cholecystectomy (1991)

(L) Carpal Tunnel release (1998), (R) release (1999)

2008

Cortisone Shots (March & July)

Arthroscopy &

meniscectomy

(June)

Arthroscopy,

chondroplasty

, partial

meniscectomy

(Dec)

2009

Orthovisc

and cortisone shots (Jan-Sep)TKA (Oct) with fibular nerve palsey  knee manipulation (Dec)PT – ionto, e-stim, strength (Nov – May 2010)

2010

EMG Nerve Study on Fibular/Femoral Nerve (June)

LLE Inching study fibular nerve (Oct)

2011

Fibular nerve release, knee manipulation (may)

More PT (14 sessions for IT band and fibular nerve pain) (Oct)

2012

More PT (12 sessions for fibular nerve and posterior knee pain) (Feb)

EMG nerve study (Nov)

2013

Epidural steroid injection (Jan)

Slide9

Examination – Systems Review

Initial

Eval

(10/20)

Weight 190lbs, 61.5” (BMI 36)

Mature scaring on anterior knee from TKA,

posterolateral

knee from fibular nerve release, small scars on wrists from carpal tunnel releases

AROM: (L) knee

ext

-50° sitting.

(L) ankle AROM appears to be WFL

PROM

: 110° (L) knee flexion, 0° (L) knee.

Strength

: 4/5 (L) knee flexion, 2/5 (L) knee extension11/15AROM: -35° left knee extDischarge (12/14) AROM: -38° left knee ext. PROM (L) ankle DF 7°Strength: Hip flexion 4/5 (B), (R) ER 3/5 (pain felt in her knee when resisted), (L) ER 4/5, (R) IR 5/5, (L) IR 3/5 (pain felt on lateral knee), and 4/5 for (L) hip abd/add/ext. (L) ankle eversion 3/5 (pain in lateral knee), 4/5 DF/PF/INV.

Palpation:

(L)

vastus

lateralis

, lateral gastrocnemius head, and distal biceps

femoris

were tender to palpation

RHR 60 BPM, BP 124/76, SaO

2

98%.

Dermatomes L

1

-L

3

feel same (B),

L

4

-S

2

diminished sensation to touch on (L) compared to

(R)

Reflexes: (R) L

3

& S

1

normal, (L) L

3

& S

1

diminished

Special Test: (+)

varus

stress

test

Slide10

Trigger Points13

Slide11

Rigor – Assessment

8

Varus

Stress Test

18

20-30° Flexion: LCL,

posterolateral

capsule, arcuate-

poplitus

complex, ITB, biceps

femoris

tendon

Extension: fibular or lateral collateral ligament, arcuate-

popliteus

complex, biceps femoris tendon, PCL, ACL, lateral gastrocnemius muscle, ITBArticle: investigated reliability of multiple knee clinical tests in CE, EUA, and by comparing to arthroscopic techniques6 (+) in CE, 10 (+) EUA (p=0.0277, Wilcoxon)Limited to collateral ligament tear: 4 subjects, 1 instability found in CE and 3 EUASensitivity = 25%, Specificity not reported

Slide12

ICF Model

Slide13

ICF Model Cont’d

Health Condition

(L) Dysfunctional Quadriceps,

(L)

fibular nerve dysfunction, (R) knee DJD

Body Structures/Function (impairments)

ROM:

(L) knee

ext

-50° sitting. PROM: 110° (L) knee flexion, 0° (L) knee. (L) ankle AROM appears to be

WFL.

*(L) ankle DF PROM 7°

Strength: 4/5

(L) knee flexion, 2/5 (L) knee

extension. *Hip flexion 4/5 (B), (R) ER 3/5 (pain felt in her knee when resisted), (L) ER 4/5, (R) IR 5/5, (L) IR 3/5 (pain felt on lateral knee), and 4/5 for (L) hip abd/add/ext. (L) ankle eversion 3/5 (pain in lateral knee), 4/5 DF/PF/INV.*Dermatomes L1-L3 feel same (B), but L4-S2 diminished sensation to touch on (L) compared to right*Reflexes: (R) L3 & S1 normal, (L) L

3

& S

1

diminished

Posterior (R) knee pain (5/10)

*

Vastus

lateralis

, lateral gastrocnemius head, and distal biceps

femoris

were tender to

palpation – guarding/trigger points?

*Laxity in lateral knee

Excessive BMI

Scars

Slide14

ICF Model Cont’d

Activities

Ambulates independently with SPC

Can transfer into/out of car with difficulty

Participation

No mention of being able to not participate in what she desires

If health condition not addressed may possibly lead to further deterioration in QOL

 need for assistive equipment, TKA revision/other knee, amputation from diabetes?

Contextual

Personal Factors (internal)

motivated to get better, pessimistic, pain in other knee/neck/back

Environmental Factor (external)

Husband/family?,

h

ome, weather

Slide15

Evaluation

Initial Evaluation

The

patient presents with

(L)

knee weakness with decreased

PROM/AROM

with increased pain with motion. The patient’s functional mobility is decreased and will be instructed on a gym program and how to operate a home NMES unit to improve quadriceps activation and knee functionality.

Reevaluation

The patient has not gained quadriceps strength like expected. Patient has laxity with

varus

stress test and is being referred back to MD.

Slide16

Diagnosis5

Pattern

5F: impaired peripheral nerve integrity and muscle performance associate with peripheral nerve

injury

She

was diagnosed with left weakness and dysfunctions S/P a left TKA with DJD in her right

knee.

ICD-9-CM

Codes

728.87 - muscle weakness-general

719.4 - joint

pain-lower

leg

Slide17

Prognosis & POC

STG

To be independent with HEP

To have EMG/NCV results by next visit

LTG

Independent with gym exercise program in 4 weeks

To improve knee extension to be -20° in 4-6 weeks

Patient Goals

Walk without use of assistive device

Be completely pain free

POC

Patient will be seen once/week for 6 weeks and be independent in a gym exercise program ASAP due to being Private Pay

Prognosis

5

Patient will demonstrate optimal peripheral nerve integrity and muscle performance over the course of 4-8 months

Expected range of visits 12-56

Slide18

Rigor – Intervention

14

Article: Review of 4 recent RCTs since 2009

Initiation: 2 days post-op, sooner the better!

Volume: 30 minutes to 4 hours per day

Intensity: The higher the better, methods to make pt. comfortable!

Adjust to supervised PT: combined modalities may possibly increase improvements

Home

unit

available to decrease costs of PT

Home exercises and free gym access while a patient.

Slide19

Patient Education

Content: Demonstrated, 1 on 1, pamphlet (NMES), flow sheet, written

instructions

Pt. instructed on NMES by demonstrating to pt. how to set it up, having the pt. repeat it, and providing written instructions & the pamphlet.

Pt’s

. concerned addressed at additional visits.

Pt. instructed on setting up recumbent bike & using clinic’s equipment with appropriate settings with demonstration & return demo (pt. able to ask available PT if confusion arises)

Pt. needed additional help 1 time with knee flexion machine.

General anatomy/physiology of condition

POC and to maintain the lowest cost

Barriers

Pt. wears glasses

Somewhat quiet (pessimistic?)

Slide20

Patient Education

Learning type: did not address patients type (maybe reflective observation?)

SPT learning style:

Accommodator

Cognitive Domain (facts) – recall exercise prescription from flow sheet, where to place electrodes (parameters on HEP), setting up equipment, comparing past PT, establish why exercises were prescribed, plan

Affective

(attitude)

– listening to instruction, participating/informed consent, going through HEP independently, resolve confusing equipment

Psychomotor (skills) – observing our demonstration, return demonstrating, practice HEP independently after learning and perfecting it

Documentation: use of NMES on location setting and duration and time/day, exercises with times on pt. flow sheet

No weight/duration in computer documentation for resistance

Slide21

Strengths & Limitations to Pt. Education

Strengths: available to help if confused with equipment, provided instructions to HEP with demo/return demo

Weaknesses: Small hand writing

(

make more legible!), was all of

pt’s

. concerns addressed?, no written instructions for D/C?

Slide22

Evaluating Clinical Change

Goals

STG: Pt.

t

o be independent with HEP at next visit (C, EF)

Following PT intervention, the pt. will be independent with a HEP and familiar with clinic gym equipment as pt. is private pay and would like to minimize cost.

LTG: To improve (R) knee extension AROM to -20° in 4-6 weeks (A, C, EF)

Following PT intervention, the pt. will improve (R) knee extension AROM in sitting to -20° to be able to transfer into a car more efficiently.

Functional Assessment

Not performed but would have wanted to use The Knee Outcome Survey Activities of Daily Living

Estimated evaluation score – 27/70 = 38.6%

Estimated discharge score – 28/70 = 40%

Slide23

Knee Outcome Survey ADLs1

2 Parts to Questionnaire – 14 total questions (also 11 question sport questionnaire)

Symptoms (6 Questions) – Pain, stiffness, swelling, giving way/buckling/shifting of knee, weakness, limping

No symptoms (5), symptoms but: does not effect activity (4), slightly affects (3), moderately affects (2), severely effects (1), unable (0)

Function – walk, ascending stairs, descending stairs, stand, kneel on front of your knee, squat, sit with knee bent, rise from chair

Activity not difficult (5), minimally difficult (4), somewhat difficult (3), fairly difficult (2), very difficult (1), unable to do (0)

 

Slide24

Knee Outcome Survey ADLs

10

Low SEM (but not the lowest)

73% of subjects score above MDC

Large ES

and ES

SEM

(4-5x SEM – indicative of sensitivity)

Smaller ceiling effect compared to other functional assessments

Missing data? – bad translation

Instrument

Pre Test (SD)

Post Test (SD)

SEM (%mean)

MDC (%>MDC*)

ICC

OKS

32.5 (7.1)

26.1 (9.3)

2.2 (7.2)

6.1 (60)

0.91

WOMAC pain

43.5 (20.5)

20.4 (18.7)

6.8 (15.2

18.8 (61)

0.91

WOMAC stiffness

47.4 (23.4)

23.5 (21.7)

9.8 (28.3)

27.1 (51)

0.84

WOMAC function

39.8 (21.4)

20.2 (18.7)

4.8 (18.5)

13.3 (61)

0.96

KOS symptoms

17.7 (6.1)

23.4 (5.1)

1.9 (19)

5.3 (60)

0.86

KOS function

20 (6.7)

28.5 (7)

1.9 (18.9)

5.3 (51)

0.93

KOS total

53.5 (15.2)

74 (15.9)

4.1 (8.6)

11.4 (73)

0.93

SF-12 PC

32.7 (7.9)

42.1 (9.4)

3.5 (10.5)

9.7 (55)

0.81

SF-12 MC

55.2 (10.7)

53.1 (9.3)

2.9 (6.6)

8.0 (56)

0.9

Slide25

Values

Patient Values

Motivation/determination

Done right quick

Hesitant

Open to new experiences, revisiting old ones

Punctual

Social support

Cost

Personal

Ambitious

Thorough/complete all tasks

Reliable/pleasing everyone

Living up to expectations

Respect honest

Fair

Slowing down

Humor

Understanding

Quickly

Black & white

PT – Professional

Goal oriented

Efficient

Equal

tx

/professional behavior

Being right or confident (knowing all)

Teachable

Organized

Responsible

Passion

Full effort

Flexibility

Realistic

Little treatment time as possible

Slide26

Johari Window

Arena

Has general

idea of diagnosis, both familiar with functional limitations

Exercise program & parameters

 written instructions

Blind Spot

PT

knows much more on anatomy of knee, differential dx, expected prognosis, how modalities/exercise affects

Share the knowledge!

Façade

Pt. may not be sharing all possible information

as there is so much history, pt. may assume we ask all that is required

Home life, kids, environment?

Ask

all appropriate history questions!

Unknown

What is truly going on and what potential is there

for rehabilitation

Refer to another specialist who can shed light on situation

Slide27

Force Field Analysis – Improved ROM

Driving Forces

Motivated to be normal

Doesn’t want to use SPC

Free gym use

Not a busy schedule/free time?

Improve function for family?

Therapy instructions/help

Restraining Forces

Weakness

Pain

$$$

Weather (winter)

Slow progress

 Doubt

Comorbidities (diabetes, back/neck pain bulge)Anatomical/Physiological knowledge

LTG: To

improve (R) knee extension AROM to -20° in 4-6

weeks – not met

Slide28

Ethical Issues

Private pay – distress

Solutions – expensive vs. least expensive

Least expensive as pt. does not have the financial resources for extensive

P

T

Pain through exercise

– issue

Solutions – modalities vs. informed consent vs. referral

Informed consent as pt. would have to pay additional for modalities, eventual referral

Code of ethics 1, 2, 3, 5, 6

Respect, trustworthy, accountable for judgment, legal/professional obligation, enhance expertise

RIPS

Slide29

Evidence Based Practice20

Functional exercises/outpatient rehabilitation better results

compared to traditional/home therapy

Benefits did not persist to 12 months

Short term rehabilitation focusing on functional exercises!

Meta-Analysis

3-4

mo

(95%CI)

12

mo

(95%CI)

Function (ES)

0.33 (0.7 – 0.58)

-0.07 (-0.28 – 0.14)

Walking (ES)

0.27 (-0.13

– 0.67)

0.03 (-0.24

– 0.31)

ROM (WM)

2.9

° (0.61° – 5.2°)

0.96

° (-1.1°

–

3°)

QoL

(ES

/WM)

1.7 (-1

– 4.3)

0.03 (-0.2

– 0.25)

Strength

N/A

N/A

Slide30

Cost/benefit analysis

Patient Private Pay Out of Pocket

PTC charges $25/unit (code 00050)

Gym free to use during business hours for current patients - $20/

mo

1 month after D/C

Potential Costs?

Commuting

TKA revision/other knee?

Conduction/genetic testing

MD visits

Role in society – pt. homemaker and has been living with this condition, overall unchanged

Fair service – I believe I would have been satisfied as I’ve seen 2 units cost ~$100 instead

Date

Cost

10/22/13

$50

10/25/13

$50

11/1/13

$50

11/15/13

$50

12/4/13

$50

Total

$250

Slide31

Outcome

So

far the patient has gained about 15° of knee extension since initial visit and feels she has improved since starting.

She

has been discharged for now until she gets further testing done on her femoral nerve function to see if she has potential for more rehabilitation.

She

mentioned she is talking with her physician about doing just a

bicompartmental

partial knee replacement in her right knee to help with pain, but is very hesitant in doing so after her current TKA dysfunction

.

Patient working with MD to get genetic testing for HNPP

May return to therapy if potential for further gains

Looking into brace to provide knee stability preventing joint

stress

Slide32

Reflection

Examination

Did a full evaluation right away

Provided functional assessment to evaluate how the patient perceives change

Mapped out

dermatones

– diabetic education?

Gathered postop reports

Biofeedback?

POC

Provided more functional exercises & adjust NMES volume

Use pain modalities – Pro bono?

Slide33

References

Knee

outcome survey activities of daily living scale (ADLS).

http://

www.ptbyart.com/media/file/341881/Knee%20Outcome%20Survey2%20RETYPED.pdf

.

Accessed March 19, 2014

.

Guide

to physical therapy practice.

2nd ed. APTA; 2003

.

Bax

L,

Staes F, Verhagen A. Does neuromuscular electrical stimulation strengthen the quadriceps femoris? A systematic review of randomised controlled trials. Sports Med. 2005;35(3):191-212.Cameron MH. Physical agents in rehabilitation: From research to practice.

Elsevier/Saunders; 2012

.

Clarke

JV, Wilson WT, Wearing SC, Picard F, Riches PE,

Deakin

AH.

Standardising

the clinical assessment of coronal knee laxity.

Proc

Inst

Mech

Eng

H

. 2012;226(9):699-708

.

Collins

NJ,

Misra

D,

Felson

DT,

Crossley

KM,

Roos

EM. Measures of knee function: International knee documentation committee (IKDC) subjective knee evaluation form, knee injury and osteoarthritis outcome score (KOOS), knee injury and osteoarthritis outcome score physical function short form (KOOS-PS), knee outcome survey activities of daily living scale (KOS-ADL),

lysholm

knee scoring scale, oxford knee score (OKS), western

ontario

and McMaster universities osteoarthritis index (WOMAC), activity rating scale (ARS), and

tegner

activity score (TAS).

Arthritis Care Res (Hoboken)

. 2011;63

Suppl

11:S208-28.

doi

: 10.1002/acr.20632; 10.1002/acr.20632

.Delport H, Labey L, De Corte R, Innocenti B, Vander Sloten J, Bellemans J. Collateral ligament strains during knee joint laxity evaluation before and after TKA. Clin Biomech (Bristol, Avon). 2013;28(7):777-782. doi: 10.1016/j.clinbiomech.2013.06.006; 10.1016/j.clinbiomech.2013.06.006.Harilainen A, Myllynen P, Rauste J, Silvennoinen E. Diagnosis of acute knee ligament injuries: The value of stress radiography compared with clinical examination, stability under anaesthesia and arthroscopic or operative findings. Ann Chir Gynaecol. 1986;75(1):37-43.Harilainen A. Evaluation of knee instability in acute ligamentous injuries. Ann Chir Gynaecol. 1987;76(5):269-273.Impellizzeri FM, Mannion AF, Leunig M, Bizzini M, Naal FD. Comparison of the reliability, responsiveness, and construct validity of 4 different questionnaires for evaluating outcomes after total knee arthroplasty. J Arthroplasty. 2011;26(6):861-869. doi: 10.1016/j.arth.2010.07.027; 10.1016/j.arth.2010.07.027.Keeney JA, Eunice S, Pashos G, Wright RW, Clohisy JC. What is the evidence for total knee arthroplasty in young patients?: A systematic review of the literature. Clin Orthop Relat Res. 2011;469(2):574-583. doi: 10.1007/s11999-010-1536-9; 10.1007/s11999-010-1536-9.Kim KM, Croy T, Hertel J, Saliba S. Effects of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction on quadriceps strength, function, and patient-oriented outcomes: A systematic review. J Orthop Sports Phys Ther

. 2010;40(7):383-391.

doi

: 10.2519/jospt.2010.3184; 10.2519/jospt.2010.3184

.

Slide34

References

Kisner

C, Colby LA.

Therapeutic exercise: Foundations and techniques.

F a Davis Company; 2007.

Kittelson

AJ, Stackhouse SK, Stevens-

Lapsley

JE. Neuromuscular electrical stimulation after total joint

arthroplasty

: A critical review of recent controlled studies.

Eur

J

Phys Rehabil Med. 2013.Koehler PJ. Hereditary neuropathy with liability to pressure palsies: The first publication (1947). Neurology. 2003;60(7):1211-1213.Levine M, McElroy K, Stakich

V,

Cicco

J. Comparing conventional physical therapy rehabilitation with neuromuscular electrical stimulation after TKA.

Orthopedics

. 2013;36(3):e319-24.

doi

: 10.3928/01477447-20130222-20; 10.3928/01477447-20130222-20

.

Losina

E,

Walensky

RP, Kessler CL, et al. Cost-effectiveness of total knee

arthroplasty

in the united states: Patient risk and hospital volume.

Arch Intern Med

. 2009;169(12):1113-21; discussion 1121-2.

doi

: 10.1001/archinternmed.2009.136; 10.1001/archinternmed.2009.136

.

Magee

DJ.

Orthopedic physical assessment.

Elsevier Health Sciences; 2007.

Malanga

GA, Andrus S, Nadler SF, McLean J. Physical examination of the knee: A review of the original test description and scientific validity of common orthopedic tests.

Arch

Phys

Med

Rehabil

. 2003;84(4):592-603.

doi

: 10.1053/apmr.2003.50026

.

Minns

Lowe CJ, Barker KL, Dewey M,

Sackley

CM. Effectiveness of physiotherapy exercise after knee

arthroplasty for osteoarthritis: Systematic review and meta-analysis of randomised controlled trials. BMJ. 2007;335(7624):812. doi: 10.1136/bmj.39311.460093.BE.Mizner RL, Petterson SC, Stevens JE, Vandenborne K, Snyder-Mackler L. Early quadriceps strength loss after total knee arthroplasty. the contributions of muscle atrophy and failure of voluntary muscle activation. J Bone Joint Surg Am. 2005;87(5):1047-1053. doi: 10.2106/JBJS.D.01992.Odum SM, Springer BD, Dennos AC, Fehring TK. National obesity trends in total knee arthroplasty. J Arthroplasty. 2013;28(8 Suppl):148-151. doi: 10.1016/j.arth.2013.02.036; 10.1016/j.arth.2013.02.036.Petterson S, Snyder-Mackler L. The use of neuromuscular electrical stimulation to improve activation deficits in a patient with chronic quadriceps strength impairments following total knee arthroplasty. J Orthop Sports Phys Ther. 2006;36(9):678-685. doi: 10.2519/jospt.2006.2305.Rasenberg EI, Lemmens JA, van Kampen A, et al. Grading medial collateral ligament injury: Comparison of MR imaging and instrumented valgus-varus laxity test-device. A prospective double-blind patient study. Eur J Radiol. 1995;21(1):18-24.Sharma L, Song J, Dunlop D, et al. Varus and valgus alignment and incident and progressive knee osteoarthritis. Ann Rheum Dis. 2010;69(11):1940-1945. doi: 10.1136/ard.2010.129742; 10.1136/ard.2010.129742.Singh JA, Lewallen

DG. Diabetes: A risk factor for poor functional outcome after total knee

arthroplasty

.

PLoS

One

. 2013;8(11):e78991.

doi

: 10.1371/journal.pone.0078991; 10.1371/journal.pone.0078991

.

Zywiel

MG, Mont MA, McGrath MS, Ulrich SD,

Bonutti

PM,

Bhave

A.

Peroneal

nerve

dysfunction

after total knee

arthroplasty

: Characterization and treatment.

J

Arthroplasty

. 2011;26(3):379-385.

doi

: 10.1016/j.arth.2010.03.020; 10.1016/j.arth.2010.03.020

.