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Ankle
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Iie
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Knee RA

BOX 11.2
MANAGEMENT GUIDELINESRheumatoid Arthritis/Active Disease Period
Impairments:
Tenderness and warmth over the involved joints with joint swelling
Muscle guarding and pain on motion
Joint stiffness and limited motion
Muscle weakness and atrophy
Potential deformity and ankylosis from the degenerative process and asymmetric muscle pull
Fatigue, malaise, sleep disorders
Restricted ADLs and IADLs
Plan of Care Interventions
1. Educate the patient.
2. Relieve pain and muscle guarding
and promote relaxation.
3. Minimize joint stiffness and
maintain available motion.
4. Minimize muscle atrophy.
5. Prevent deformity and protect
the joint structures.
Precautions: Respect fatigue and increased pain; do not overstress osteoporotic bone or lax ligaments.
Contraindications: Do not stretch swollen joints or apply heavy resistance exercise that cause joint stress.
1. Inform the patient on importance of rest, joint protection, energy conservation,
and performance of ROM.
Teach home exercise program and activity modifications that conserve energy
and minimize stress to vulnerable joints.
2. Modalities.
Gentle massage.
Immobilize in splint.
Relaxation techniques.
3. Passive or active-assistive ROM within limits of pain, gradual progression as
tolerated.
Gentle joint techniques using grade I or II oscillations.
4. Gentle isometrics in pain-free positions, progression to ROM when tolerated.
5. Use of supportive and assistive equipment for all pathologically active joints.
Good bed positioning while resting.
Avoidance of activities that stress the joints.

OA

BOX 11.4
MANAGEMENT GUIDELINESOsteoarthritis
Impairments:
Pain with mechanical stress or excessive activity
Pain at rest in the advanced stages
Stiffness after inactivity
Limitation of motion
Muscle weakness
Decreased proprioception and balance
Functional limitations in ADLs and IADLs
Plan of Care Intervention
1. Educate the patient.
2. Decrease effects of stiffness.
3. Decrease pain from mechanical
stress and prevent deforming forces.
4. Increase ROM.
5. Improve neuromuscular control,
strength, and muscle endurance.
6. Improve balance.
7. Improve physical conditioning.
Precautions: When strengthening supporting muscles, increased pain in the joint during or following resistive
exercises
probably means that too great a weight is being used or stress is being placed at an inappropriate part of the
ROM. Analyze
the joint mechanics and at what point during the range the greatest compressive forces are occurring. Maximum
resistance exercise should not be performed through that ROM.
1. Teach about deforming forces and prevention.
Teach home exercise program to reinforce interventions and minimize symptoms.
2. Active ROM
Joint-play mobilization techniques.
3. Splinting and/or assistive equipment to minimize stress or to correct faulty biomechanics,
strengthen supporting muscles.
Alternate activity with periods of rest.
4. Stretch muscle, joint, or soft tissue restrictions with specific techniques.
5. Low-intensity resistance exercises and muscle repetitions.
6. Balance training activities.
7. Nonimpact or low-impact aerobic exercise.
BOX 11.8
MANAGEMENT GUIDELINESPostfracture/Period of Immobilization
Impairments:
Initially, inflammation and swelling
In the immobilized area, progressive muscle atrophy, contracture formation, cartilage degeneration, and
decreased circulation
Potential overall body weakening if confined to bed
Functional limitations imposed by the fracture site and method of immobilization used
Plan of Care Intervention
1. Educate the patient.
2. Decrease effects of inflammation during
acute period.
3. Decrease effects of immobilization.
4. If patient is confined to bed, maintain
strength and ROM in major muscle groups.
1. Teach functional adaptations.
Teach safe ambulation, bed mobility.
2. Ice, elevation.
3. Intermittent muscle setting.
Active ROM to joints above and below immobilized region.
4. Resistive exercises to major muscle groups not immobilized, especially
in preparation for future ambulation.

BOX 11.9
MANAGEMENT GUIDELINESPostfracture/Postimmobilization
Impairments:
Pain with movement, which progressively decreases
Decreased ROM
Decreased joint play
Scar tissue adhesions
Decreased strength and endurance
Plan of Care Interventions
1. Educate the patient.
2. Provide protection until
radiologically healed.
3. Initiate active exercises.
4. Increase joint and soft tissue
mobility.
5. Increase strength and muscle
endurance.
6. Improve cardiorespiratory fitness.
Precautions: No stretch or resistive forces distal to the fracture site until the bone is radiologically healed. No
excessive
joint compression or shear for several weeks after the period of immobilization. Use protected weight bearing
until the site
is radiologically healed.
1. Inform patient of limitations until fracture site is radiologically healed.
Teach home exercises that reinforce interventions.
2. Use partial weight bearing in lower extremity and nonstressful activities in the
upper extremity.
3. Active ROM, gentle multiangle isometrics.
4. Initiate joint play stretching techniques (using grades III and IV) with the force
applied proximal to the healing fracture site.
For muscle stretching, apply the force proximal to the healing fracture site until
radiologically healed.
5. As the ROM increases and the bone heals, initiate resistive and repetitive
exercises.
6. Initiate safe aerobic exercises that do not stress the fracture site until it is healed.

BOX 12.5
MANAGEMENT GUIDELINESPostoperative Rehabilitation
Impairments:
Postoperative pain because of disruption of soft tissue
Postoperative swelling
Potential circulatory and pulmonary complications
Joint stiffness or limitation of motion because of injury to soft tissue and necessary postoperative immobilization
Muscle atrophy because of immobilization
Loss of strength for functional activities
Limitation of weight bearing
Potential loss of strength and mobility in unoperated joints
Maximum Protection Phase
Plan of Care Interventions
1. Educate the patient in preparation
for self-management.
2. Decrease postoperative pain,
muscle guarding, or spasm.
1. Instruction in safe positioning and limb movements and special postoperative
precautions or contraindications.
2. Relaxation exercises.
Use of modalities such as transcutaneous nerve stimulation (TNS), cold, or heat.
Continuous passive motion (CPM) during the early postoperative period.
C H A P T E R 1 2 Surgical Interventions and Postoperative Management 333
Plan of Care Interventions
3. Prevent wound infection.
4. Minimize postoperative swelling.
5. Prevent circulatory and pulmonary complications
such as deep vein thrombosis,
pulmonary embolus, or pneumonia.
6. Prevent unnecessary, residual joint
stiffness, or soft tissue contractures.
7. Minimize muscle atrophy across
immobilized joints.
8. Maintain motion and strength in areas
above and below the operative site.
9. Maintain functional mobility while
protecting the operative site.
3. Instruction or review of proper cleaning and dressing the incision.
4. Elevation of the operated extremity.
Active muscle pumping exercises at the distal joints.
Use of compression garment.
Gentle distal-to-proximal massage.69
5. Active exercises to distal musculature.
Deep-breathing and coughing exercises.
6. CPM or passive or active-assistive ROM initiated in the immediate
postoperative period.
7. Muscle-setting exercises.
8. Active and resistive ROM exercises to unoperated areas.
9. Adaptive equipment and assistive devices.
Plan of Care Interventions
1. Educate the patient.
2. Gradually restore soft-tissue and joint
mobility.
3. Establish a mobile scar.
4. Strengthen involved muscles and
improve joint stability.
1. Teach the patient to monitor the effects of the exercise program and make
adjustments if swelling or pain increases.
2. Active-assistive or active ROM within limits of pain.
Joint mobilization procedures.
3. Gentle massage across and around the maturing scar.
4. Multiple-angle isometrics against increasing resistance.
Alternating isometrics and rhythmic stabilization procedures.
Dynamic exercise against light resistance in open- and closed-chain positions.
Light functional activities with operated limb.
Moderate Protection/Controlled Motion Phase
Plan of Care Interventions
1. Continue patient education.
2. Prevent reinjury or postoperative
complications.
3. Restore full joint and soft-tissue mobility,
if possible.
4. Maximize muscle performance, dynamic
stability, and neuromuscular control.
5. Restore balance and coordinated movement.
6. Acquire or relearn specific motor skills.
Precautions: In addition to the precautions already addressed that relate to the stages of tissue repair and
healing, there are
several additional precautions that are of particular importance to the postsurgical patient.
Avoid positions, movements, or weight bearing that could compromise the integrity of the surgical repair.
Keep the wound clean to avoid postoperative infection. Monitor for wound drainage and signs of systemic or
local infection,
such as elevated temperature.
Avoid vigorous/high-intensity stretching or resistance exercises with soft tissues, such as muscles, tendons, or
joint capsules
that have been repaired or reattached for at least 6 weeks to ensure adequate healing and stability.
Modify level and selection of physical activities, if necessary, to prevent premature wear and tear of repaired or
reconstructed
soft tissues and joints.
1. Emphasize gradual but progressive incorporation of improved muscle performance,
mobility, and balance into functional activities.
2. Reinforce self-monitoring and review the signs and symptoms of excessive
use; identify unsafe activities.
3. Joint stretching (mobilization) and self-stretching techniques.
4. Progressive strengthening exercises using higher loads and speeds and
combined movement patterns.
Integrate movements and positions into exercises that simulate functional
activities.
5. Progressive balance and coordination training.
6. Apply principles of motor learning (appropriate practice and feedback
during task-specific training).
Minimum Protection/Return to Function Phase

502 PAINFUL SHOULDER SYNDROMES: NONOPERATIVE MANAGEMENT

Impingement syndromes and other painful shoulder conditions
have varying etiologic factors and therefore can be
categorized several ways.
Based on Degree or Stage of Pathology
of the Rotator Cuff (Neers Classification
of Rotator Cuff Disease)118
Stage I. Edema, hemorrhage (patient usually _ 25 years
of age)
Stage II. Tendinitis/bursitis and fibrosis (patient usually
25 to 40 years of age)
Stage III. Bone spurs and tendon rupture (patient usually
_ 40 years of age)
Based on Impaired Tissue41
Supraspinatus tendinitis
Infraspinatus tendinitis
Bicipital tendinitis
Subdeltoid (subacromial) bursitis
Other musculotendinous strains (specific to type of injury
or trauma)
Anteriorfrom overuse with racket sports (pectoralis
minor, subscapularis, coracobrachialis, short head of
biceps strain)
Inferiorfrom motor vehicle trauma (long head of triceps,
serratus anterior strain)
Based on Mechanical Disruption and
Direction of Instability or Subluxation
Multidirectional instability from lax capsule with or
without impingement
Unidirectional instability (anterior, posterior, or inferior)
with or without impingement
Traumatic injury with tears of capsule and/or labrum
Insidious (atraumatic) onset from repetitive microtrauma
Inherent laxity
Based on Progressive Microtrauma
(Jobes classification)88
Group 1. Pure impingement (usually in an older recreational
athlete with partial undersurface rotator cuff tear
and subacromial bursitis)
Group 2. Impingement associated with labral and/or capsular
injury, instability, and secondary impingement
Group 3. Hyperelastic soft tissues resulting in anterior or
multidirectional instability and impingement (usually
attenuated but intact labrum, undersurface rotator cuff
tear)
Group 4. Anterior instability without associated impingement
(result of trauma; results in partial or complete dislocation)
Based on Degree and Frequency
Instability subluxation dislocation
Acute, recurrent, fixed

Knee

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