TKR Back home in PA

[jmark87]

Juniper, that was quite a time you had with the kidney stone. I hope I never get one. I have taken a little time off before I think three days. That was before MUA, now I am starting over.

 

[jmark87]

To Orthodoc:
I read one of your posts on MUA. Here is my situaton. BTKR 5/15/12, did weeks of PT. The OS said I could work on knees myself at the gym and pool. Continued this but could not get past 100 and 90 degrees, R and L. When I visited OS on 7/16 he saw I was bound up with adhesions and said he could stretch them, "MUA". I had that done on 7/19. Back to PT next day and three times a week since. I am not getting any more flexion and the knees are sore all the time. I am so confused by the quotes on this forum about less is more and don't work knees if stiff and swollen. I just don't know how to balance between working them, resting/elevating/icing. They are quite uncomfortable when walking and exercising. Any suggestions? If I lay off working them for three or four days, will this do any good or will lose what I have? Today I am one week from MUA.
Thank you for your time.

 

[juniper]

I hope Josephine weighs in on this. In my humble opinion, the more you can rest, with your legs up (not necessarily raise above your head all the time, but up) with a bit of walking and very gentle stretching, like knee slides,the better you'll be. See Roy's post in my thread which has been renamed...turning a corner or something like that. Because I am finally getting how much rest is needed and I'm doing it. Oh, and I thought adhesions needed to be "removed" not merely stretched. I'll have to head back to the library.

 

[Josephine]

John, I am so sorry we are confusing you. Let me try and give you some more simple directions.

First, as you said, you are only one week from an MUA and your knee is bound to still be swollen and painful, yes? Second, you are only 10 weeks out from the surgery itself. More swelling and pain. If you remember that article I left you about the swollen stiff knee and why it happens, you will see that this has to be managed along with your exercises. What I am saying is that laying off for 3 to 4 days isn't the answer. You need to do a little less each day every day and rest, elevate and ice lots more in between plus take pain meds on a regular basis.

Can I give you a kind of timetable? Of course, I don't know what you've been given to do so I will work on my own intuition on that.

9am: 30 mins of exercise, 20 mins of walking followed by at least an hour of rest, icing and elevation.
1.30: same again
6.30: same again

That's the kind of routine you need. Gentle exercise with lots of rest and icing.
Plus you need to take your pain meds totally as prescribed and don't miss a dose or reduce it, not for the bext couple of weeks anyway.

You see, the biggest challenge is not about the flexion, it's about the swelling and pain. Get that under control and the flexion will come, you'll see. There's no need to make yourself miserable like this. Okay?

 

[jmark87]

John, I am so sorry we are confusing you. Let me try and give you some more simple directions.

First, as you said, you are only one week from an MUA and your knee is bound to still be swollen and painful, yes? Second, you are only 10 weeks out from the surgery itself. More swelling and pain. If you remember that article I left you about the swollen stiff knee and why it happens, you will see that this has to be managed along with your exercises. What I am saying is that laying off for 3 to 4 days isn't the answer. You need to do a little less each day every day and rest, elevate and ice lots more in between plus take pain meds on a regular basis.

Can I give you a kind of timetable? Of course, I don't know what you've been given to do so I will work on my own intuition on that.

9am: 30 mins of exercise, 20 mins of walking followed by at least an hour of rest, icing and elevation.
1.30: same again
6.30: same again

That's the kind of routine you need. Gentle exercise with lots of rest and icing.
Plus you need to take your pain meds totally as prescribed and don't miss a dose or reduce it, not for the bext couple of weeks anyway.

You see, the biggest challenge is not about the flexion, it's about the swelling and pain. Get that under control and the flexion will come, you'll see. There's no need to make yourself miserable like this. Okay?

Josephine, first I want to say that I clicked the "Like" button and then it said Unlike, you know what I mean. Explain the emphasis on pain meds. The obvious is to reduce the pain but will they let me stretch a little further since I won't have as much discomfort? Today at PT I measured 96° and 99°. At first I did not think the icing was doing very much, now that I am icing five or six times a day, I feel that it is really helping me.

 

[referee54]

Icing is very important---the more you ice, the greater chance you have of eliminating some of the inflammation and the swelling---and that will calm the knee down and allow you to build some ROM. Ice and elevate as often as you can---it will work and help to allow the knee to become less angry and more cooperative.

 

[1ELISEA]

Icing is so important. Glad that it is helping you! Feel better!

 

[bottomshollow]

John, FYI---clicking the "Like" on the right hand side creates a message on the left hand side which says you like the post. The "Like" changes to "Unlike" to allow you to change your mind if you want to or if you clicked it by accident.

 

[Orthodoc]

First, as you said, you are only one week from an MUA and your knee is bound to still be swollen and painful, yes? Second, you are only 10 weeks out from the surgery itself. More swelling and pain.

9am: 30 mins of exercise, 20 mins of walking followed by at least an hour of rest, icing and elevation.
1.30: same again
6.30: same again

That's the kind of routine you need. Gentle exercise with lots of rest and icing.

Jmark86,

After reading about your current situation, I think that the advice given above is very appropriate.

Give it some time and keep up the diligent work.

Orthodoc

 

[ChrisO]

You know what the definition of crazy is? Doing the same thing over and over again and expecting a different outcome.

Got to go, have my straight jacket in the drier... Don't want it to shrink or wrinkle.

 

[jmark87]

Thanks for your analysis.

 

[Jamie]

John, the theory behind having proper pain management is that when your knees are not inflamed and irritated, you will have less swelling and therefore great ROM. The irritation and inflammation can also cause an accelerated development of scar tissue, so you want to do everything to avoid that possibility for the weeks and months following your MUA as well as your surgery. Taking your meds on a set schedule will ensure that you always have pain medication in your system. Waiting to take them until you start to feel pain means you'll be playing catch up and that is not as effective in managing the pain.

This program is not forever.....but it is important for most people to do it this way when they are early in recovery as you are.

 

[juniper]

OK Jamie, I get what you're saying, but then why do any exercise at all in the first weeks? Why isn't recovery completely about rest and elevation and icing so that you get the swelling and inflammation down?

It seems that most of the confusion John and I (and many others on this site) have is based on the balance between rest and exercise. That seems to be the difference between treatment in the UK, New Zealand and the US. I was actually surprised that Josephine recommended as much exercise and walking for John so soon after MUA, but then when I was hurting, even during very first weeks post op, the doc told me "Ice for twenty minutes, no more." Jo says ice for an hour each time. I also didn't realize that inflammation causes adhesions. I thought that was just an individual thing, some people get them, some don't.

Recently, someone here in Pennsylvania told me that the PT was bending the he** out of her leg so that she didn't get adhesions. Go figure.

 

[jmark87]

I don't think I am getting the connection between pain meds and inflammation. I assume the inflammation comes from working the knees and not icing/elevation. If you are on pain meds I would think that you would have a tendency to over work since you don't feel the pain. How do the meds help keeping down the inflammation, that was the question?
To answer Chris, I don't think I am insane.

 

[ChrisO]

John,

I don't think your insane either, no more insane than me and most of the people who post their frustrations about the speed and trajectory of their post TKR recovery. Talk about insane... I signed the consent forms for my knee knowing the mechanics of a knee replacement and assuming my recovery would take about 6 weeks. All this after I had talked my OS into doing bilat when he didn't want to - said the serious complication rate (death and other serious end points) was higher w/ Bis and recovery was harder. I convinced him that I was young (lower risk of death), strong and didn't have enough sick time to invest in two acute recovery episode. I went to the hospital locked into the idea that I would be back to work within 6 weeks. No one could convince me otherwise.

I had my surgery on 05/22/12 and I'm still not at peace with the speed and trajectory of my recovery. I have an uneasy truce with my body I don't push too much and it doesn't hurt me too much. These wonderful bones smart people have been telling me the same things they are telling you and I love them dearly for it but tend to ignore 40-60% of what I know is reasonable and sound advice. That's what I mean by crazy.

My comments were not meant to offend only to point out the fact that people tend to be stubborn.

ChrisO

 

[ChrisO]

OK so about the pain… I am a cardiac nurse not a pain nurse so keep that in mind when reading this post.
Pain has a purpose. It helps prevent us from hurting ourselves further and slows us down to allow tissues to heal.
The body has a least two feedback loops that involve pain.
The most immediate feedback loop is nerve mediated. When something hurts us we feel it. Nerve mediated pain can be strong enough to immediately stop a muscle from working. This is why most of us can’t walk on even a stable broken leg because the injury-pain-nerve feedback loop is arresting the muscles ability to contract.
Some people believe that the nerve mediated pain feedback loop can go nuts and begin to propagate pain (actually grow nerves pathways that generate pain!) this pain is often way out of proportion to the visible deformity or injury. This sort of pain can remain even when the tissue has healed. Some think that if pain is allowed to continue without adequate relief for long periods of time this can happen. This syndrome is called Chronic Pain Syndrome.

I think the most difficult to understand is the chemical hormonal mediated pain response feedback loop. When tissue is injured it releases chemicals that tell the body it is hurt. The body responds by increasing the blood flow to the area. This causes swelling and heat. But the swelling is just a side effect of the fact the body is doing its job. Our bodies are bathing the injured tissue in as much good stuff as the blood stream can bring, WBCs to fight infection and remove damaged cells, RBCs to provide oxygen, food and protein to begin the process of growing new cells. Unfortunately the chemical hormonal feedback loop is not as simple as our nerves. We can push a swollen body part to continue to work, the pain from swelling is usually something we can overcome but it isn’t always something we should try to overcome. Swelling means injured tissue, swelling means injured tissue, generally the more swelling the more injury but there are many exceptions to that rule. Everybody responds differently.
Pain can cause a negative hormone mediated response also. When we are in pain we emit stress hormones among other things stress hormones can cause cells to emit pro inflammatory cytokines (chemicals that tell other cells to become inflamed or cytokines can even tell our immune cells to attack healthy tissues.) Stress responses can actually drive tissue to the point of failure. We are becoming more and more aware that having excessive amounts of these chemicals loose in our bodies over time is not at all good for us. They are linked to everything from heart disease to arthritis to Alzheimer’s.
Therefore untreated and ignored pain can really cause more pain, slow recovery and possibly cause more injury.

 

[bottomshollow]

Chris---an excellent post, great explanation. I think it deserves to be included in our Library. I am tagging Jamie to be sure she sees it.

 

[Jamie]

That is an excellent explanation, Chris. Thank you so much!! Josephine

Juniper, the reason you need to do some gentle exercises in the early days of recovery is that, while rest, ice, elevation and pain management are important, so is movement of the joint. You never want to be totally immobile since that could result in problems moving the joint properly later. But....there is a world of difference between gentle bending and stretching and the workouts that some of these therapists and surgeons recommend. The former should not result in additional pain and swelling....just adequate movement to keep the joint loosened up and moving. The latter can result in pain and swelling.

Please notice that I say "can".....it doesn't happen for everyone and you will find people who swear by pushing their new joints to perform. You see, recovery just is not a cut and dried thing. It is different for everyone. But generally when we see someone who is pushing hard and complaining of pain, the problem is they are doing more than their body is ready for. This happens very frequently and it's why you'll hear us tell folks to slow down over and over again. You have to pay attention to what YOUR body's response is to your activity level. It is a balance and sometimes it can be difficult to achieve. Fortunately if you overdo things one day, you can get back on track by just taking a few days off with lesser activity.

Also....notice that I didn't say there was a cause and effect relationship with inflammation and adhesions or scar tissue. That is not the case. No one can say for sure who will develop adhesions and who won't. What I was saying is that inflammation can contribute to their formation in some people. It's not a given, but you would want to keep inflammation at a minimum to reduce the possibility. Actually, formation of adhestions is not the norm following joint replacement surgery. Please read Josephine's article on MUAs in the BoneSmart Library and you will have a better understanding of why a small percentage of people have this happen.

I am sorry if all this seems confusing to you. The reality is that there is no set guide for recovery that works for everyone. We recommend things here on BoneSmart based on what has worked for the majority of our members (and in Jo's case what she has seen in her 50+ years of orthopedic experience). We can give you guidelines, but at some point you must determine when something is working for your body and when it isn't.

John.....you're partially right about inflammation. It can come from working the tissues before they are ready. But it is also a natural result of surgery.....the body is assaulted and tissues can become inflamed as a result of that as well. There is also a cycle that can be set in place with pain where unmanaged pain increases the inflammation and that in turn causes more pain. This is what Chris was describing in her post.

I hope this additional information is helpful. I wish I could give you specific rules or cause and effect relationships, but that's just not possible.

 

[referee54]

One point that I feel should be made is that we have to find out how to stay within ourselves during gentle exercises and find a method to resist overdoing it---at least too many times. It is important to work the joint to keep it loose as well as to slowly build muscle strength and stamina.

Too little effort in exercising can be as bad as too much exercise.

I also was one of the folks that had adhesions---and my OS as well as the PT mentioned that it was not my lack of PT or exercise that led to the situation---it was genetics and luck of the draw, so to speak.

 

[juniper]

Thanks to all (Chris, Jamie, Tim) who helped once again to explain TKR pain, inflammation, the need for gentle exercise and the mystery of adhesions. These posts are hugely helpful to me. And I'm going to be returning to them. Hearing it once is clearly not enough for many of us. Thank you. Thank you. Thank you.