Post-Operative Total Knee Arthroplasty in an Older Adult with Multiple Comorbidities
A 78-year-old woman is 3 days post left total knee arthroplasty (TKA). She has a history of type 2 diabetes (HbA1c 7.8%), hypertension, and mild cognitive impairment (MCI). She lives alone in a second-floor apartment with 15 steps and no elevator. Her current pain is 6/10 at rest, 8/10 with movement. Knee ROM: flexion 70°, extension lag 10°. She is using a walker with moderate assistance for transfers and ambulation of 10 feet. Her Berg Balance Scale score is 32/56. She reports fear of falling and has had two falls in the past year. The PT must decide on discharge destination and intensity of intervention.
1. What are the key factors influencing this patient's discharge destination, and what would you recommend?
Read the worked answer
Key factors: 1) Home environment: Second-floor apartment with 15 steps and no elevator is a significant barrier given her current mobility. 2) Cognitive status: MCI may affect safety awareness and ability to follow a home exercise program. 3) Social support: Lives alone, so no one to assist with ADLs or emergencies. 4) Physical function: Berg Balance Score 32/56 indicates high fall risk; requires moderate assistance for transfers and ambulation; limited knee ROM and extension lag. 5) Comorbidities: Diabetes and hypertension require monitoring. 6) Fear of falling and history of falls. Recommendation: Given the unsafe home environment, cognitive impairment, and high fall risk, discharge to a skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF) for intensive PT and safe transition is appropriate. If home discharge is considered, a comprehensive home safety evaluation, possible home modifications (e.g., stairlift, bedside commode), and 24/7 supervision would be necessary. However, the patient's living alone and MCI make home discharge unsafe at this time. The PT should advocate for continued rehabilitation in a supervised setting.
2. What would be your primary PT goals and interventions for the next week, and how would you monitor progress?
Read the worked answer
Goals: 1) Improve knee ROM to at least 90° flexion and full extension to facilitate functional mobility. 2) Reduce fall risk by improving balance and transfer independence. 3) Increase ambulation distance to 50 feet with minimal assistance. Interventions: 1) ROM: Low-intensity stretching, heel slides, and use of CPM if appropriate; emphasize terminal knee extension. 2) Strengthening: Quadriceps and hip abductor strengthening within pain limits. 3) Balance and gait training: Progressive balance exercises, gait training with walker, and stair negotiation practice if appropriate. 4) Pain management: Coordinate with nursing for pre-medication before therapy. 5) Education: Fall prevention strategies, home safety, and use of assistive device. Monitoring: Track ROM via goniometry, Berg Balance Scale weekly, ambulation distance and assistance level, and pain scores. Also monitor blood glucose before and after exercise due to diabetes.