The Significance of Kneeling Progressions in Knee Replacement Rehabilitation

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones Dives into why working on kneeling is not a matter of IF we should do it but WHEN. Dustin covers a sequence of kneeling progressions, designed to gradually expose patents to kneeling in a manner where they have control over how much they flex their knee & how much pressure they allow onto the knee cap.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

DUSTIN JONESWhat's up crew, good morning and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division and today we are going to be talking about kneeling after a total knee replacement. kneeling after a total knee replacement. We're gonna dive into this somewhat hot topic if you will or debatable issue that we come across so often with our folks but more importantly give you progressions so you can actually get people's knees to touch the ground again. Alright this is a big issue that in my clinical experience I would often see the detriment of people not working on kneeling you know years decades after they had said surgery and it was really eye-opening for me and I'm sure many of you all as well to see what that does to people when they go for so long thinking that they are not allowed to kneel to let their knee apply pressure to the ground or that they're they're just afraid to right just think of all the functional implications that that has when you are scared to death to let that knee kiss the ground to be able to pick something up off the ground to be able to play with your grandkids to be able to kneel and garden right this is a This has huge implications for our patient's quality of lives and what's unfortunate is that it's often neglected, right? You think about your standard post-op protocol, what are you working on, right? You're trying to get full range of motion, trying to get that full extension, then really working on getting that flexion to be symmetrical with the other side. We're working on our strength deficits, we're working on our balance. and working on getting back to their independence in terms of gait as quickly as possible. But how many of y'all are getting applying pressure to the knee and progressing it to the manner where they're doing half kneeling, full kneeling, floor transfers, burpees, for example. How often is that getting neglected in the rehab setting? And it is far too common, far too common. NO EVIDENCE THAT KNEELING IS HARMFUL AFTER JOINT REPLACEMENT Now the unfortunate reality is we do not have any evidence to state that kneeling is actually harmful for individuals after they've had a knee replacement. There's even a really good article in the Journal of Knee Surgery, all right, so this is an orthopedic surgeon journal, in 2020, that basically said, I'm gonna read this verbatim, which I love this, there is no biomechanical or clinical evidence contraindicating kneeling after a total knee replacement. I'm gonna repeat that again for the folks in the back, there is no biomechanical or clinical evidence contraindicating kneeling after a total knee replacement. The folks that wrote this article and this quote are orthopedic surgeons from Johns Hopkins University that work in the orthopedic surgery department. These folks are doing lots and lots of total knee replacements, doing lots of follow-up visits. And they're saying there's no reason why we should not be kneeling with these folks. So I think for us as rehab providers and some fitness professionals as well that watch this or listen to this, it's not a question of if we're going to kneel, it's more a question of when. When are we going to kneel in that rehabilitation process? And how do we progress people to the point where they can bear full weight on those knees and trust that they're going to be just fine, right? KNEELING PROGRESSION So let's kind of go through some of these progressions. I'm going to do a reel later on, probably the next couple of days, giving you some tangible video examples. but I'm going to talk through this, especially for the folks that are listening, we'll make sure that you're able to understand kind of this progression that we're talking about here. Alright, so kneeling progressions, this could be in the span of, you know, a few visits for some of your patients, it could be the span of weeks, but there's some important things that we want to have when we're talking about kneeling progressions. is an Airex pad or some type of pillow, right? The home healthers, you got a pillow, probably have an Airex pad as well, right? But you want a soft surface that is mobile, that you can apply to different surfaces, like when you go to the ground, when you go to a box, for example, or some type of elevated surface. You want something that you can take in terms of a soft surface. That's going to be very, very helpful for that individual. And then you want to have good elevated surface options. In the home, it is the couch, right? It is maybe a step. It is a kitchen chair. It's a recliner. It's a bed. In the clinic, it's a therapy table. It may be a plyometric box that you can apply the Airex pad on to give some padding. It may be a lobby chair, for example. Or a bench is another one. You want to have lots of options for these elevated surfaces. So typically when we're thinking about kneeling, where we want to start is with just manual overpressure into extension, maybe their legs just propped up, that person is applying pressure themselves. They are in control, and that first entry into kneeling, we want to do it in a manner where they feel like they're in control. You're probably already doing some manual overpressure, working on getting that full extension back, so we're already covering that, but that is going to translate well when we're applying pressure to kneeling, all right? So doing all that work that you're already doing to get range of motion, that's a good place to start when we're thinking about getting to the point full kneeling. The big thing is that they are applying that pressure. We want them to be in control. because that is going to give them the ability to probably progress a little bit quicker. Alright, so manual overpressure, we're already doing that stuff. Now we're talking about actually getting maybe in a standing position or we're talking about maybe getting to a kneeling position. You want to think about what available flexion do they have, right? And what is the status of the incision? Is the incision healed? Is the scar tissue solid? Are we not worried about any splitting, any tearing, any bleeding, so on and so forth. So if we're kind of well past that healing phase, then all right, we're somewhere, we're in a good spot, but we also wanna be considerate of how much flexion that they have. So if they are really struggling with their flexion, let's say they don't have 90 degrees, or 90 degrees is really tough, we can still apply kneeling in a 45, 60 degree angle, but in a standing position where they're going to apply pressure into a horizontal, or sorry, a vertical surface, all right? So let's say you're standing, your knee is bent to 45, 60 degrees, can have some type of vertical surface. In the home health setting where I would do this, it would be a kitchen cabinet, typically, and I would have some type of padded surface. I would get them to bend as much as they're able to bend, and I would have them shift their weight and basically think about putting their knee into that cabinet or that vertical surface, applying pressure in that manner. They're still in control. They are grading how much pressure they're applying, but they're getting used to applying force through that knee. Alright, now when we get more or closer to full range of motion, 90 degrees is real easy for them to do, then we can think about tall kneeling. When we go tall kneeling, what can be helpful is to have one leg on the ground and one leg on an elevated surface, right, like a bed is a great example, but what's really important here is to have upper extremity support. In the home setting, what I typically do is at a kitchen counter, so I have the hand on the counter and And then I would have a chair on the same side as the surgical side. I would have a cushioned mat, like an Eric's pad, for example. They would put that knee on that chair, and then with their hands, they would shift their weight, shift their weight. They would be grading that pressure, and over time, they would get more and more comfortable, all right? The upper extremity support is really important. Some type of cabinet. If you're in a clinic with parallel bars, that's really great as well. That's going to be very helpful for these individuals. All right, that checks out. Awesome. Let's go on to quadruped. Bed therapy table can be very, very helpful where we're able to really grade that pressure and they're able to rock and shift back and forth. applying more and more pressure to that surgical side. Once they're in quadruped, you are 75% home, right? If they're able to get in that quad position, you're in a really good spot. This is where we're going to start working our way to the ground. Now, when we go to the ground, you want to think about the softness of that surface, right? That's going to be way more tolerable for many of these individuals in a really hard, cold surface. So, if you have maybe a gymnastics pad, if you can maneuver that Arix pad that you've been carrying around under their knee when they're going to the ground, that can be really helpful. You may have a set of knee sleeves. which can be very, very helpful for these individuals. Or you may say, hey, let's get on, you know, two pairs of sweatpants, for example. So just think of some cushion and some padding. When you go down to the ground, that's going to make it a little bit easier for folks. Then we can go all the way to the ground, get in quad, work on getting in prone, working on coming up. In this phase, you do want to have some upper extremity support around. We cover this extensively in our MOA live course where you troubleshoot floor transfers, but there are certain positions where you want a box or a chair at certain phases of a floor transfer that's going to make it conducive for them to be able to use their upper extremities. But have a chair around that you can move around so you can place it appropriately. they can put their upper extremities on it and help grade some of that pressure that they're experiencing through the knee. And as we're working on floor transfers, and they're getting pretty comfortable going to the ground and up from the ground, that's where we may just speed it up, where we may go on to a full-blown burpee, right? So this progression from kind of that manual overpressure early on, still kind of worried about the incision side, we don't have full range of motion, to where they've got partial range we can start to do some standing, not necessarily kneeling, but driving that knee into a vertical surface if they can't get that full 90 degrees and then we're progressing it down to where they're in that quad position doing floor transfers and progressing to a burpee. This is a kneeling progression that almost all of us can do with our folks in some way, shape, or form, right? And I challenge you clinicians watching right now that are listening right now. Zach Kaufman, what's up? I challenge you all to not think of if you want to consider kneeling in your post-op protocol or plan. It's more a matter of when. You need to do it. I've seen the implications of what that means for folks 10, 20 years down the road when they have had the fear of God instilled in them to get down on their knees. dramatically lowers their quality of life and what they are able to do and what they choose to do. It is absolutely sad to watch and you can prevent that by incorporating kneeling and kneeling progression into your plan of care that you're gonna give this person so much freedom to experience so many good things in life when they have the ability to let their knee hit the ground. All right, appreciate y'all. Let me know your take on kneeling after total knee replacement. We could say total hip as well. It's just as applicable for hip replacements too, but let me know your thoughts in the comments of this YouTube video or hit us up on YouTube podcast listeners. We'd love to have you jump on social media. I think this is a really important discussion, something that we often neglect, and I think we need to really change that narrative. All right, appreciate y'all watching. Have a good one. SUMMARY Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.