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The Paley Rehabilitation Center
Physical Therapy (PT)
The Paley Advanced Limb Lengthening Institute’s Rehabilitation Department is committed to providing patients with the highest quality physical therapy to ensure a successful outcome following surgery.
Dr. Paley guides the therapy team in the development of the individual treatment plans for each patient which are designed to achieve successful, functional results. Using developmentally appropriate strategies, our therapists carefully consider each patient’s needs, then plan and execute their therapy accordingly. We provide education about the entire rehabilitation process throughout the patient’s care.
The protocols for the rehabilitation of the limb-lengthening patient are based on the phase of the diagnostic and healing process.
Physical therapy evaluation may be performed preoperatively when warranted. This is done in order to establish a relationship, determine any special concerns that the patient may have, and determine baseline measurements prior to surgery. Evaluation will include past medical and surgical history, pain level, preoperative range of motion (ROM), strength, sensation, limb-length discrepancy and/or deformity, posture, coordination, and functional mobility including transitions and gait. Initiation of an exercise program may be needed prior to surgery to address identified deficits. The preoperative visit is also useful to educate the family and patient on what to expect after surgery, fit the patient for assistive devices, and establish realistic postoperative goals.
Acute Hospitalization Phase:
After surgery the hospitalization phase usually lasts from three to five days, during which the patient receives physical therapy twice daily and occupational therapy one to two times per day. Evaluation begins the first post-operative day and continues daily until discharge to home. PT management consists of pain and edema control, splinting, performance of exercises, functional activities, and transfers. Custom splints need to be fabricated to help elongate the soft tissues (muscles and tendons) properly during lengthening, and will be worn 22 hours per day to prevent contracture. Exercises begin the day after surgery and include isometric and range-of-motion exercises. Functional mobility—including bed mobility, transfers, and activities of daily living will be emphasized. In order to facilitate a smooth transition from discharge to outpatient physcial therapy, we provide ongoing patient and parent education.
Tweny-four to forty-eight hours after discharge from the hospital, the patient will begin outpatient physical therapy at the PALLI Rehabilitation Department. Our therapists will communicate with the hospital-based therapists and will be familiar with the patient’s progress before their evaluation. The patient should be sure to take his or her pain medication 30 minutes before the physical therapy.
The evaluation will identify any precautions based on Dr. Paley’s prescription and assess pain, integument, A/PROM, strength, mobility, sensation, balance, and coordination. Psychosocial factors affecting progress will also be addressed throughout treatment. Outpatient PT is recommended daily (five days per week), including one hour of land-based and one hour of aquatic exercise when deemed appropriate. Home exercises are also prescribed. The patient and family are given handouts or videos to ensure proper technique. Goals of PT are to maximize A/PROM, prevent contractures, improve strength and mobility, and promote the maximum possible level of functional independence. Balance activities will include weight shifting and proprioception, steadily progressing toward walking with progressive weight bearing and minimal deviations.
Prior to stretches, moist heat will be applied to the thigh and can be coupled with electrical stimulation as indicated by the treating therapist. All attempts are made to manage pain with a variety of techniques, including proper medication management, thorough preparation prior to stretching, use of distraction techniques, and modalities to alleviate pain. Soft tissue release and joint mobilization prior to stretches will help to decrease the discomfort associated with muscle lengthening. Special care will be taken to avoid undue pull on skin surrounding pin sites, and can consist of careful hand placement or splinting of the skin by the patient or helper during stretching.
Aquatic PT can begin 7 to 10 days after surgery when active bleeding has ceased. Aquatic exercises will incorporate movement in a warm, buoyant environment, utilize as much AROM as possible, and include manual stretches as noted in land-based protocol. This environment is particularly helpful in allowing active range of motion, in strengthening hip abductors, quadriceps, and gatro-soleus complex to limit gait complications, and in helping to keep the pin sites clean.
During this phase, the initial focus is on reclaiming full ROM (range of motion), eliminating muscle restriction left over from the lengthening phase, and progressing gait, balance, and strength. Emphasis is on functional and closed chain strengthening activities as much as possible. Frequency of treatment may initially be five times per week if ROM restrictions are significant, but will decrease to three times per week as ROM is restored. The home exercise program continues to be an integral part of recovery. Patients usually return to their hometowns for this phase, and the PALLI Rehab Department supports home-based therapists with videos of the current program and guidelines for progression.
Once the external fixators are removed, the patient may be casted or non-weight bearing for approximately one month.This allows bone growth through the pin sites, which are inherently weak areas prone to fracture at this point. While non-weight bearing, the patient can continue with AROM activities, but PROM and manual stretches are contraindicated as the risk of fracture is high.
Once PT resumes, hip, knee, and ankle PROM will begin without restrictions, and may take months to return to normal limits if severely limited from the lengthening process. As a rule of thumb, 10 degrees per month can be expected to return per joint. Following lower-extremity lengthening, the hip abductors, quadriceps, and gastro-soleus complex are always the weakest and can lead to altered gait. Active ROM of the lower extremities with a progressive emphasis on strengthening these muscles is key to re-establishing a normal gait pattern.
Once a radiological review has been completed, the patient will be cleared to begin partial weight bearing and progress to full weight bearing as bone density indicates. High impact activities such as running, jumping, and plyometric activities should not be part of the patient’s movement repertoire as the bone density does not support this type of impact for 6 to 8 weeks after fixator removal. Dr Paley will clear the patient for return to sports upon radiological examination and strength assessment.