The client has likely been looking forward to their knee replacement surgery for quite some time. Maybe they have been unable to complete their ADLs or IADLs without extensive pain for years. Maybe they have reduced their participation in leisure activities or stopped doing them completely.
They are hoping this surgery will give them their life back, but they are not entirely sure what to expect during the recovery process. Occupational therapists can play a very significant role in helping clients with knee replacements return home and resume normal activities after an acute care stay.
Occupational therapy evaluations of patients after knee replacement may take place on the day of surgery, known as post-op day zero.
“In some facilities, the occupational therapy evaluation may take place the day after surgery.”
If the evaluation does take place on post-op day zero, it is very important to review the chart and communicate with nursing prior to seeing the patient. The patient may still be groggy from anesthesia or medication. Also, 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, also 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.
All patients experience pain differently. Patients may have no pain or extensive pain on the day of surgery, depending on medications. You may need to educate patients to keep and stay on track of their pain medication schedules. Also, the therapy schedule may need to be modified if the client is having extensive pain. Be sure the patient keeps ice on their knee between sessions to help reduce the 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 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 equipment such 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.
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?
“Check with the doctor about advising patients when to shower, as this might depend on the type of wound dressing they have.”
A shower seat, transfer tub bench, and/or a grab bar may be recommended for safety. Transfer tub benches are very 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 transfer tub bench, the client can back up to the seat, then lift their legs into the tub while seated instead of standing to left their legs into the tub. You may need to recommend locations where this adaptive equipment can be obtained/purchased. Also, to prepare for the client’s 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 the 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.
“If you don't have a leg lifter handy, you can use their gait belt!”
Car transfers can be simulated by using a transfer tub bench if one is available in your facility. A trash can turned on its side is one idea that can be used to simulate the car door threshold.
Acute care stays following knee replacements are typically pretty short (maybe 1-2 days). Therefore, discharge planning starts during the evaluation! It is nice when the client’s family or caregiver is present during therapy sessions, so they can see how much assistance the client will need upon discharge and make home modifications or arrange for more in-home assistance if needed.
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 discuss if the family will be able to assist with set-up and maintenance of this) 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.”
There are a lot of important points to address before a client is discharged after having a knee replacement surgery. From adapting poor ROM and pain management to proper home set-up and independence with ADLs and IADLs, occupational therapists may be able to help clients and their families to problem-solve and work through situations that they had not anticipated in order to ensure a safe discharge home