Total Joint Replacement Rehabilitation 10/05/11 08:08 p.m.

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Total Joint Replacement Rehabilitation

Author: Abraham T Rasul Jr, MD; Chief Editor: Rene Cailliet, MD more...

Updated: Jan 20, 2010

Medical Care During Rehabilitation

Treatment and monitoring of medical comorbidities
During the initial evaluation of the patient, the physician must perform a thorough physical examination, not just
an examination of the affected joint. Associated medical conditions also need to be identified and addressed.
These comorbidities directly impact the outcome of rehabilitation. Communicating with the patient's primary care
physician ensures that there is continuity of treatment of associated medical conditions. Medications may need
to be changed or modified, depending on the patient's vital signs and laboratory profiles.

Pain control

Adequate analgesia for the patient should be a priority during rehabilitation. [2] It must be remembered that these
patients have undergone a major joint reconstruction and may experience moderate to severe pain. The
administration of analgesics should be performed around the clock rather than just on an as needed (prn) basis.
With prn dosing schedules, the analgesics are usually given too close to the time that the patients are seen for
therapeutic exercises. Patients complain of pain and are not as cooperative as they would have been had they
been following a regular pain medication schedule.

A long-acting narcotic analgesic provides extended pain relief in appropriate cases. Attention to side effects of
these narcotic analgesics is a priority. Elderly patients are prone to develop side effects, such as mental status
changes, which limit their participation in rehabilitation sessions. These individuals are perceived as confused
and uncooperative; therefore, they are thought of as poor candidates for rehabilitation. Long-acting narcotic
analgesics should be tapered once this becomes appropriate and should subsequently be changed to a prn
schedule.

Determination of the cause of pain is a very important aspect of pain treatment. The physician may want to take
the following questions into consideration:

Is the patient suffering from pain at the operative site or from joint pain, periarticular pain, or neuropathic
or radicular pain?
Is the pain associated with fever?
Is the pain associated with weight bearing or range of motion (ROM)?
Is there evidence of a vascular compromise associated with the pain?

An appropriate diagnostic work-up should be performed to identify the cause of pain. This work-up may include
the following:

Complete blood cell (CBC) count, wound cultures, and erythrocyte sedimentation rate (ESR) tests are
performed in cases of suggested infection.
If appropriate, electromyogram (EMG) and radiologic tests, including radiography, ultrasonography,
magnetic resonance imaging (MRI), or computed tomography (CT) scanning, should be performed in
cases that suggest nerve injury. Radiologic evaluations may be limited to plain films because the
presence of the metallic implant limits the use of MRI and CT scanning. It should be remembered that
with any surgical procedure, complications, such as infection and neurovascular injuries, can cause
postoperative pain.

Bowel and bladder functions

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Total Joint Replacement Rehabilitation 10/05/11 08:08 p.m.

Constipation is one of the most frequent complaints during rehabilitation. This condition can be caused by
decreased mobility or postanesthesia effects; it can also be a side effect of narcotic analgesics. If
untreated, constipation can lead to nausea and vomiting, bowel obstruction, or even sepsis, especially in
the elderly patient. An adequate bowel program, using stool softeners and laxatives, is needed. An
enema may be appropriate in some cases. At times, patients are admitted to the rehabilitation unit with a
Foley catheter still in place. The Foley catheter should be removed if there has been no problem with
bladder retention. Patients with persistent bladder dysfunction should be referred to a urologist for
evaluation.

Nutrition and hydration

Elderly patients have always been at risk for malnutrition or dehydration stemming from physical limitations or
cognitive deficits. These patients need to be screened by a dietitian for appropriate nutritional intake.
Dehydration can lead to acute metabolic or renal problems that affect the patient's participation in the
rehabilitation program.

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