TKR Careful! There Be Dragons Here! <

[Nvstig8tr]

@charmed-life - I love your description of my incident as an "Accidental Manipulation" so I've added the phrase to my post. Thanks! And @uva55 has suggested that I bill my insurance company for the procedure! Ha! That's a good one!

Thanks everyone!

From the moment I walked into the physical therapy facility, I felt they were all about money and billable hours and running me through a cookie-cutter protocol that NEVER took into consideration the trauma I had experienced in the TKR. I was treated like a contestant on the "Biggest Loser" being whipped into shape by the expert trainers who wouldn't take "no" for an answer and who resorted to guilt/manipulation in order to intimidate and beat me into submission. Well, they're the biggest losers, not me!

Final Note: I slept for 4 hours straight last night after taking 2 Tramadol and 2 Tylenol PM at midnight. Also, I started out on my side (at first), but at some point I must have gotten uncomfortable, because I woke up on my back. Baby steps!

 

[Suz]

I think a letter stating what you experienced from that PT facility would 'possibly' help others in the future. Maybe finding contact information on a Regional Office? I'm just so glad you are wise now as to what's best for you Bill!

 

[Josephine]

He said the incision would be "sealed" within 24 hours of removing the staples. Just to make sure I understood him, I asked "What about these Steri-Strips?" and he said it could take several days for them to fall off on their own, but I could get in the pool before they come off.

This always amuses me. I cannot for the life of me think what benefit there is in not touching the Steristrips until they fall off! That's just stupid! In the UK they are removed after about a week or so. I know if I left Steristrips on my skin more than a week, I'd have blisters like gangbusters!

They put the Physical Therapist on the phone and he advised me that he thought it was a waste of my time and his time for me to continue coming into the facility for outpatient PT. He also told me that he had contacted my OS and shared with him that I had been a very difficult patient and unwilling to permit them to do their job. I'm sure I'll hear all about it next Tuesday morning when I see my OS again.

You have to laugh as such an arrogant attitude, don't you? I mean, who died and made him king?

Besides which, in my experience (UK though, not US) if a PT did call the surgeon and complain about a patient in that way, he'd be more likely to ask "Why, what have you done to offend the patient?"! We had one (UK) member whose PT threatened that, adding that the surgeon would be very angry that the patient had 'ruined a five and half thousand pound knee"! I had to laugh at that as no surgeon I know would waste his time getting outraged at such a thing as that! (threat, threat, threat!!)

I was treated like a contestant on the "Biggest Loser" being whipped into shape by the expert trainers who wouldn't take "no" for an answer and who resorted to guilt/manipulation in order to intimidate and beat me into submission. Well, they're the biggest losers, not me!

Good for you! That kind of attitude is just great to see.

 

[Nvstig8tr]

Do Any Scholarly Articles Support the BoneSmart Mantras?

Please don't take this as a criticism, but when I have searched the BS reference library and the forum threads for articles that I could give to my OS or PT, it seems that EVERYTHING is generated from within the BS community by Josephine or other Forum Advisors or Senior Members. While that's great for encouraging one another, those outside the BS forum would label everything as anecdotal or lacking any serious foundations for their consideration as surgeons or physical therapists.

For example, I would love to see even one scholarly (or published) article that would address the following issues we face in joint recovery:

• The "Window of Opportunity" constantly being used by surgeons and physical therapists as a weapon to beat us into submission.
• The importance of not allowing physical therapy or activity to reach a level that could be described as pain; and the difference between pain and discomfort.
• Insufficient, poorly-designed, lack of a standard protocol in pain management following a joint replacement.
• Swelling and stiffness following joint replacement: how these factors affect recovery and therapy.

It seems to me that we will never change the system unless we can re-educate the orthopedic surgeons and physical therapists; and this will only be accomplished by giving them information they believe is legitimate (from peers within the medical community).

 

[sistersinhim]

I wish they'd listen to the real experts, we who have experience in rehabbing our knees!

 

[Pumpkin]

Bill,
I am going to tag @Josephine to address your questions.

IMO, For aggressive rehab, there is no evidence or research beyond anecdotal, and the OS opinion.

 

[newlybionic]

I will say that when I contacted my OS office about if there was any types of things I should not do with my new knee after my revision their quote to me was to ' not do anything that hurts'. While this is not an article that has been published this OS is a highly trained one that successfully does hip and knee revisions on many patients crippled by their first surgeons. He has gone through a rigorous school and fellowship and he lectures throughout the US. The PT I had never caused me any pain. Discomfort at times yes, but no real pain. No step ups, no side leg lifts, no weights. I'm currently 130,0 which is excellent after a revision. It's looks like it's the same with my non surgical knee. I do have some stiffness at times and a twinge now and again. The only problem I'm having now with my 10 - 11 hour work days is some back issues which I think might be related to some core muscle weakness.

 

[KarriB]

Bill, after my infection/washout surgery a month after the original TKR my Revsion surgeon wanted my knee immobile. It stayed immobile for a month. I saw my dr twice a week and each time I asked him if my knee would ever bend again, he always responded that my knee would bend when we told it to bend. When I was finally allowed to bend, he ordered non-aggressive bending and demonstrated this by pushing my foot about 2 inches with his foot, sliding it on the floor. Now I'm not sure that's his philosophy with all patients, but he felt my soft tissue wouldn't respond well to aggressive therapy. Here's an article I found;

https://sbfphc.wordpress.com/2013/0...hysical-therapy-after-total-knee-replacement/

 

[KarriB]

Reading the comments on the above link, I see that Josephine commented on behalf of BS.

 

[Celle]

Bill, my surgeon and his group of four other Os's all recommend minimum PT after a knee replacement. They allow no formal Pt for the first month, and then only one visit every two weeks. I don't know the statistics of the other 3 surgeons, but my own surgeon's patients all do well and he has not had to do a MUA to help with ROM for the past 3 years.

If your own PT has been trained to believe that aggressive Pt is the way to rehab after a TKR, I don't think anything you say or show him will change his mind. It's probably best just to trust you own judgement, going by what feels best for your own knee.

I have a friend who is a PT. She tells me that the refresher courses for PTs in her area are now recommended a gentler approach to helping TKR patient with recovery.

@KarriB
Thanks for the article above.
I find one of the assumptions in the comments a little misleading, as "Passive" therapy is quoted as the alternative to "Aggressive" therapy. As I understand it, Passive PT involves no action from the patient, but is done by the therapist, moving the patient's limbs him/her self. Not the best for recovery from a TKR, because is it active movement, performed by the patient, that accomplishes best results.
As a comparison, knee bending using a CPM is passive movement. A person doing Heel Slides is doing active movement. While using the CPM machine may feel good to some people and stop the knee from feeling stiff, it doesn't do anything long-term to improve ROM.

 

[Dawni]

Bill this is my second TKR the first being nearly 5 years ago each time I followed the BS mantra each time I have had a very good bend 130-0 this time I only went to PT twice they said my bend was so good I did not need to go, they said I must have been doing my exercises as instructed as I left I told my PT I had not done any she thought I was joking, but beleve me it works

LTKR 11 May 2016

 

[KarriB]

@Celle I guess because my OS prescribed "non-aggressive" pt for me then demonstrated what that was upon my request I just assumed passive was the same. But I understand what you're saying about passive pt. Thank you for the explanation.

Here is another study I found from the Netherlands. It doesn't say no therapy, but studied the difference between less therapy once a day and more therapy twice a day.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1579215/

 

[mbouck3]

The Pt's are protecting their livelihood, only natural. Its all about the money especially in the good old U.S. of A

 

[sistersinhim]

@KarriB, thank you for finding those articles. At least we're seeing that there is interest in this subject out there.

 

[Josephine]

I can only tell you that opinions in medicine change very slowly. I do remember that in the early days (pre 1990) there was no PT prescribed for any joint replacement. How and when it come into being, I have no idea but it seems to have got worse and worse over the years. I've worked at some prestigious hospitals during my career and while we probably weren't doing the number of joint replacements are now there was enough to know if the protocols they had were working our not. I never heard about this aggressive PT and these sayings such as the window of opportunity until I came on BoneSmart in 2007 and it really alarmed me. I asked around of surgeons I was working with and also from surgeons I met at the many medical conferences I attended. Not once did I hear any positive reactions to these issues. I also had relatives, friends and acquaintances who had hips and knees done and were not given any exercise routines to follow. Not one of them had problems as a result.

So I started advising people to not engage in anything that would cause them pain and what do you know - they got better and better! Had less swelling and pain and their ROM improved. I also had a number of members post that their ROM had improved months later and even as long as a year later. This body of opinion has just grown and grown over the years since and that's what I base my opinion on.

The importance of not allowing physical therapy or activity to reach a level that could be described as pain; and the difference between pain and discomfort.

Then it came time for me to have a knee replacement and wouldn't you know it, my surgeon told me not to do any exercising for at least the first three weeks, just rest, elevate, ice and pain meds. (You really thought I made that up myself, perhaps?!) I found that after those three weeks I actually had pretty good ROM so I never did any at all and I never regretted it. When I had my second knee done, I deliberately did none and got an even better result which seemed to clinch it for me.

I was also encouraged by various members such as Celle who had done little or no exercise and still had very good results. Also of numerous members who had started out on the 'aggressive' path, ended up in great pain and distress and then, having followed my advice, found things change dramatically and they ultimately ended up with excellent results. The evidence on BoneSmart is staggering!

The "Window of Opportunity" constantly being used by surgeons and physical therapists as a weapon to beat us into submission.
Swelling and stiffness following joint replacement: how these factors affect recovery and therapy.

There is this article in the Scientific Articles section of the Library. These are all papers taken from peer reviewed medical journals. This one in particular address your concern Myth busting: the "window of opportunity" JBJS

For me though, these are just a matter of common sense, summed up in the article Swollen and stiff knee: what causes it?

Insufficient, poorly-designed, lack of a standard protocol in pain management following a joint replacement.

I can't think you would take this as being anything less than common sense either. Of course there are different types of pain and there are many ways of described them
1. soreness, burning, stabbing, throbbing, aching, swelling and stiffness
2. aching, tender, sharp, hot, burning, nagging, intense, stabbing, tingling, dull, throbbing (LINK)
3. Peripheral neuropathic pain is often described as "burning", "tingling", "electrical", "stabbing", or "pins and needles" (LINK)

I would add this - I belong to a University research group and a few weeks ago was discussing this with one of the professors. His immediate reaction was that this went again 'generations' of thinking and teaching. But he was also open to it and is right now considering applying for a research grant to do a study on it. I am very hopeful that this will come to pass.

Just to show I am not biased in this respect, I also posted this article in Scientific Articles in the Library
Aggressive Rehab Safe After Knee Replacement

And more
MUA: the ineffectiveness of early MUA JBJS
MUA for Stiffness Following TKR
Evaluation and Management of the Stiff TKA and MUA
Pain after knee replacement JBJS

 

[Josephine]

Here is another study I found from the Netherlands. It doesn't say no therapy, but studied the difference between less therapy once a day and more therapy twice a day.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1579215/

Good on yer, Karri! That one will be added to this article in the Library which says much the same thing!
TKR: Evidence shows that less really is more when it comes to exercising!

 

[Floridagal]

I have found this discussion very interesting. I have progressed well doing minimal exercises. I don't follow the home program the PTs have given me only doing what feels right and doesn't hurt. I am appreciative of all the research on this area and it makes good common sense. I am happy that my PTs are not the arrogant SOBs that have been described. They listen carefully to me and don't push me too hard. I know that I can be my worst enemy because I want to excel. I am working on that. Thanks to you all for the information.

 

[Celle]

@Celle I guess because my OS prescribed "non-aggressive" pt for me then demonstrated what that was upon my request I just assumed passive was the same. But I understand what you're saying about passive pt. Thank you for the explanation.

@KarriB - It may also be a difference in terminology between the US and the UK. When I was working as a nurse in the UK, patients who had been paralysed by strokes, or spinal or head injuries, received passive physiotherapy to their immobile limbs, with the aim of preventing contraction deformities of their limbs from developing. The bending and straightening movements were similar to those that a CPM machine provides, I think.

 

[Josephine]

Indeed.
'active' movements mean the patient is moving their leg/arm under their own power with no assistance
'passive' movements mean someone else is moving the leg/arm for the patient
'gentle' means just that!
'aggressive' means they are pushing to the point of pain and probably in excess of it

 

[KarriB]

As I told Josephine a while ago, a friend of my mother had a TKR at the mayo clinic. She drove from Pittsburgh to Mayo because she didn't trust anyone else to do the TKR. Her OS at the Mayo Clinic prescribed no formal pt, just daily living. She allowed my OS to remove her staples and do her follow up because he had done a fellowship at Mayo, the same OS who prescribed non-aggressive pt for me.

I believe there are pockets across the country that embrace this philosophy. My first PTs were what I would call "doc in a box" pt which are in neighborhoods across the country. Two weeks put they put weights on my knee and had me doing squats, which I refused because they hurt. My second pt group had me on a bike, a self propelled CPM machine and lots of wonderful massage, then at 4 months I was on a treadmill, stepping over low cones and strength building, none of which caused any pain or discomfort. The key has to be researching to find who works best for you.