TKR Freedom works on recovery<<

[Freedom]

wednesday I had my initial outpatient PT meeting - basically the assessment. (LTKR was Jan 20th, in home PT ended 2 weeks ago). Took history, checked and marked out my area which is numb, measured extension, flexion, and moved my knee cap a lot. Both knees, as he wanted me to feel how much it moves on the 'old' knee, vs. the new knee which is stiff and tight. He wants me in PT 3xweek: 2 times on land, one in water. Then we went to the scheduler: first pool opening is NEXT Friday; and she only found one land session, on Tuesday. He said they can't work miracles, I have extensive scar tissue build up; at one point he was using all his body weight to try and bend my knee, it would not move (did not hurt, either). Said I am good and stuck, not sure they can help me. Will give it one month. Then if no progress, back to OS for either MUA or open it up and remove all the scar tissue. Thursday, both knees were EXTREMELY sore and stiff, surgical one more so; has to be that knee cap action! OMGosh, that is all we did and I can barely next day. And in future we "start" the PT?! LOL Anyone else have these big gaps between sessions of PT? Now trying to find either a massage therapist or a chiropractor who works with scar tissue breakdown, as I want to avoid any more hospitalizations. Has anyone had success with that? I also saw there is an ultrasound therapy which breaks down scar tissue? I'm all for non invasive at this point!!!

 

[Celle]

checked and marked out my area which is numb, measured extension, flexion, and moved my knee cap a lot. Both knees, as he wanted me to feel how much it moves on the 'old' knee, vs. the new knee which is stiff and tight. He wants me in PT 3xweek: 2 times on land, one in water. Then we went to the scheduler: first pool opening is NEXT Friday; and she only found one land session, on Tuesday. He said they can't work miracles, I have extensive scar tissue build up; at one point he was using all his body weight to try and bend my knee, it would not move (did not hurt, either). Said I am good and stuck, not sure they can help me. Will give it one month. Then if no progress, back to OS for either MUA or open it up and remove all the scar tissue. Thursday, both knees were EXTREMELY sore and stiff, surgical one more so; has to be that knee cap action!

I don't like the sound of all this!

First, it's far too early for your PT to be telling you that you have extensive scar tissue or worrying you with te threat of a MUA. It just does not build up as fast as that. In any case, if you do have adhesions (the proper name for what your PT is talking about) more PT won't cure them.
The main thing stopping your bend is swelling. Your knee can't bend easily because the swelling is making it stiff - just like a garden hose full of water. Concentrate on reducing the swelling, with rest, ice and elevation and your knee will naturally start to bend more. You don't have to do lots of exercise to rehab a knee. Whatever you do, don't let the PT push on your knee or try to force it.
Scar tissue and adhesions - what's the difference?
Myth busting: the "window of opportunity" in TKR
Knee recovery - Lose the Work Ethic!!

Second, your kneecap will mobilise itself as time passes. You had major surgery and things inside are still swollen and inflamed. There is no need to do anything to mobilise it.

Third, that numb area will go or decrease when the nerves regenerate. Nothing you can do will influence that.
Numb area after TKR: how long will it last?

 

[Freedom]

This is why I post on here; I need a reality check! Even the PA told me, if I don't get improvement in 4 to 6 weeks, they will do a MUA. So I had no reason to question the PT.

I have been worrying about an MUA since Week 2! And each time I get sorted out here, then someone else throws in their 2 cents and off I go again worrying.

 

[Celle]

@Freedom
The big thing to remember is that no one can do a MUA without your consent. It's your knee and only you have the right to say what will happen to it. Others may advise, but the decision is yours alone.

I think it's unkind,irresponsible and unprofessional for doctors and PTs to use the threat of a MUA to frighten their patients into overworking their new knees.

You don't have to work hard to rehab a TKR knee.
For what it's worth, my surgeon does not allow any PT for the first month after a TKR. He says the knee needs that time, to start on its healing. After that, he only allows a small amount of gentle PT (I did no PT at all).
His patients all do well and he hasn't had to do a MUA for the last 3 years.

 

[Freedom]

So is this again an insurance thing? Does insurance only cover if you continue to improve and if you don't get the MUA within a certain time then they don't cover it? Otherwise, I can't see why they keep pushing for you to go to PT get that bend get that straightening, etc.

I was supposed to have my second knee done next month but OS has pushed that back to another 3 to 4 months, due to this first one not being where he wants it.

Next week, I have Monday Massage, Wed land PT and Fri pool PT.

 

[Celle]

To a certain extent it is an insurance thing. Measuring and recording ROM is one way in which the PTs can prove that their ministrations are effective - and so they become number-obsessed. Just because that's their focus doesn't mean it has to be yours. Your focus is what is best for your knee and you should let your knee dictate how fast it progresses.

Another thing is that many PTs were taught the myth about the window of opportunity and they fully believe it. Some refresher courses are now teaching that a slower, more gentle approach to rehabilitation is better for your knee.

My surgeon doesn't measure your knee. He looks at it and says "Show me what you can do." He can assess, just by looking a it, how well the knee is progressing and he maintains that what you can do with your knee (function) is more important than the numbers.

 

[Freedom]

Well, my function is frustrating at this time! I have to have my car door completely open in order to get in or out. Which means parking in a parking lot is a challenge; have to ensure no one pulls in next to me too close! Happened once already, and I was stuck, couldn't get back in my car. Had the person paged but no response. Had to wait over half an hour.

My gait is not smooth, and the ground regularly comes up and trips me! I haven't fallen (yet!) but have done some interesting dance moves.

 

[Celle]

I know it's difficult getting into and out of your car, but that is going to improve.
It's still very early in this year-long recovery and where you are now is not where you will end up.

 

[jarabas]

Hi Freedom,

I had my surgery a month before you. I was experiencing the problems you mention getting in and out of the car until 2 weeks ago and it has pretty much gone away! The pavement has also mostly stopped tripping me up although I have a much harder time on grass.
I'll be interested to see where you are in a couple more weeks.

 

[Celle]

I, too, had problems with the pavement tripping me up. I found that consciously lifting my foot a little higher solved the problem.

 

[sleepilu]

Tripping on pavements must be down to confidence outdoors. I toddle and clonk happily round the house with a stick but turn into a very stick dependent woman outdoors.
For what it's worth I have a 4" toilet seat (not bragging, just tall!) and I lurve it!!


Sent from my iPhone using BoneSmart Forum

 

[karol723]

I haven't tripped yet outdoors, but walking isn't so smooth. I feel like I'm doing fine in the house, the I go outside & suddenly I'm hesitating and feel so vulnerable ! Guess it's normal at this stage.

 

[Celle]

Although I didn't really need to use it, I would take my walking stick with me when I went outside. It gave me some additional confidence that I wouldn't fall and it was useful for warding off rushing people and dogs.

Even now (at 18 months after surgery) it's still in my car, jut in case conditions underfoot are slippery.

 

[Freedom]

I had half an hour of massage on Monday morning. I must say, it was FANTASTIC! This woman is certified to work with joint issues (and yes I WILL get the specifics on that certification, next visit), and has worked with knee replacement folks many times. She has also worked with some of them pre op. She will not work with you unless you are also in PT. She said massage is not in place of PT.

I have never had any sort of massage before, and I have a lot of swelling still. So she said she was taking it easy this first time, and working with the lymph system to address the swelling. She said neither PT nor massage should EVER hurt. She used coconut oil on her hands. It was very relaxing. I had to run errands afterwards, was out and about for 3 hours before I went home. Would have preferred to head home to ice and elevate. Still, the swelling was down and the knee felt "normal" for over 9 HOURS! Then slowly the swelling and stiffness returned, as she said it would.

I don't think I improved flexion at all but just feeling so good for 9 hours was worth EVERY PENNY! (Insurance does not pay for massage). I finally start outpatient PT, tomorrow Wed I have land, and Friday I have pool PT. So I spread it out, don't want to start too many things all at once, and I return for massage again next week.

Also, once I see what they have me do and not do -- or not do YET -- in the pool etc., I want to return to the Y and start working out on my own. Obviously I can do upper body stuff, no problem. So I have a plan, massage, PT and Y work outs, and this should help me with my recovery.

 

[jarabas]

I'm doing something quite similar and very happy with the results so far. It's such a relief to be getting out and taking an active part in recovery. The pool therapy might be my favorite--where I go it's warm, the water is about 3-4.5 feet deep and I don't worry about falling down.

 

[Freedom]

I have FINALLY started outpatient PT. I will go 3 times a week, till end of May (I do have to be assessed monthly to be sure I am making improvements). Two sessions per week will be land, and one session will be in the pool. Land will be Monday afternoons at 2:30, and Friday (3 in the morning the rest are afternoon). Pool will be Thursday mornings. Today, Mar 16, Wed, was my first LAND session, and this Friday will be my first pool session. Outpatient PT today went well. Basically, I was lying on the table looking at the ceiling or on my stomach looking at the curtain. She did all the work. She did not measure today. We could both tell the ROM improved a LOT during that hour. She identified that all my issue appears to be at the knee cap, everything else moves fine. Quad is firing, and the stretches to isolate muscles all went fine. So she spent most of the time on the knee cap area, pulling, pushing, massaging. None of it hurt. Then at the end, I was on my stomach, leg hanging over end of table, she put a 5 pound ankle weight on my ankle, set timer for 2 minutes. Removed weight, and she did the bend, as far as she could till I said stop. Then she said she would hold it there for 15 seconds. After 30 seconds I said, "Are you slowly increasing the bend?" Therapist - laughing: "Maybe! But you and your knee are allowing me to do it!" Back to another 2 minutes with the ankle weight, and then 10 minutes of icing before I left. I was almost nauseous going in, and ready to cry, I was so scared. IT WAS FINE!!!

Home instructions: DO YOUR EXERCISES. Obviously, I don't. This is why I want to get going back to the Y. I am more likely to do stuff there, than sitting here at home alone with the cats and dogs, lol. I feel like I am finally getting a routine going, something which has been completely missing from my recovery plan until now. I have massage again next Tues and, now that I have my PT schedule, that will be easier to schedule going forward. I guess I will have to try things, doing Massage on a non PT day, or before or after a land PT session. Just about the time I figure it out, I will be done ha haaa. Because YES at some point, I WILL be done with this! And ready to move on to the rest of my life!

 

[Celle]

So she spent most of the time on the knee cap area, pulling, pushing, massaging. None of it hurt. Then at the end, I was on my stomach, leg hanging over end of table, she put a 5 pound ankle weight on my ankle, set timer for 2 minutes. Removed weight, and she did the bend, as far as she could till I said stop. Then she said she would hold it there for 15 seconds. After 30 seconds I said, "Are you slowly increasing the bend?" Therapist - laughing: "Maybe! But you and your knee are allowing me to do it!" Back to another 2 minutes with the ankle weight, and then 10 minutes of icing before I left. I was almost nauseous going in, and ready to cry, I was so scared. IT WAS FINE!!!

Your kneecap will mobilise itself as you continue to heal. I jut don't understand why some PTs in the US obsess about mobilising it. Nobody worries about that in the UK or in NZ and our kneecaps move just fine.

Please, please, tell your PT not to use weights again. It is actually bad for your knee, even if it doesn't hurt. There is no need to rush to get ROM, no window of opportunity, because ROM can continue to improve for a year, or even longer, after a TKR.
Myth busting: the "window of opportunity" in TKR

You don't have to work hard to rehab your knee, but any exercise you do should be with your own efforts, not passive movement by a PT.
TKR: work “smarter” and not “harder”
Knee recovery - Lose the Work Ethic!!

It sounds as if your knee is recovering very well. Just do a little, gentle exercise and concentrate on continuing to reduce the swelling, with rest, ice and elevation.

 

[Freedom]

Well at 8 weeks post op, I am at 72 flex and -10 extension. That is not ''the norm," I am well behind. My knee area is stiff and tight. Today I actually am moving more freely.

I worry now as I don't know what is 'right' for PT and what is not; I tend to let them be the expert. Now you are saying what she is doing is not good for me.

Also, is anyone aware, the links in "Myth Busting" do not work?

OK, the exercise we did with the weights, that is actually #3 on the Extension: Exercises for improvement. So are you saying the Bone Smart library item is wrong?

The links in Pain after Knee Replacement do not work, either.

 

[Celle]

What she is doing is all too much to start with. That's what I'm saying. If you do too much exercise, too soon, you run the risk of increasing swelling, which will slow down you ROM improvement. Also, I've looked back at your very first post and it looks as if, right from the start, your knee was overworked. If that continues to happen, it could set up a chronic inflammation.

The link to article about the window of opportunity worked OK for me. However, I've re-loaded it. See if it works now. If it still doesn't work, go back to the first page of your thread, Post #2, where Josephine posted the recovery reading list. The article is there, too.

Pain after knee replacement - this worked OK for me too, but here it is again.

If you look again at the article on exercises for extension, you'll see that it recommends this: "Begin with 1 lb. and gradually add another pound of weight (to a maximum of 5 lb.) each week for the 20-minute sessions." It doesn't say start with a 5 lb weight, which is what your therapist did.
It often takes longer to achieve extension than flexion. You get the best results by working at it slowly and steadily, because your tendons and ligaments will have shrunk and it takes time for them to adjust and lengthen again.

 

[Freedom]

Also, I've looked back at your very first post and it looks as if, right from the start, your knee was overworked. If that continues to happen, it could set up a chronic inflammation.

??? I have no idea what you read, but I had 5 days of uncontrolled pain, so there was NO PT at that point. Then when PT did start, at the inpatient rehab, I was doing very little. I was so pain averse at that point, anticipating pain in everything, that we did very little. Didn 't do stairs until Day 10 post op. Yes, I did alot in that one day I did PT and had a shower, but what I did in PT was little. The therapists were constantly stumped what to do with me, as I would not allow anyone to touch, they had to explain / demonstrate and then I would do it, or try it.

The link to article about the window of opportunity worked OK for me.

The link to THAT article works fine. It is all the links WITHIN that article which do not work. I had to go back into the Library to find the individual articles. Same for this one:

Pain after knee replacement - it works fine. The links WITHIN it do not work, so you have to back out to the Library and poke around to find the articles -- which are not in alphabetical order and some are in one section, some are in another so you poke around a bit.

If you look again at the article on exercises for extension, you'll see that it recommends this: "Begin with 1 lb. and gradually add another pound of weight (to a maximum of 5 lb.) each week for the 20-minute sessions." It doesn't say start with a 5 lb weight, which is what your therapist did.
It often takes longer to achieve extension than flexion. You get the best results by working at it slowly and steadily, because your tendons and ligaments will have shrunk and it takes time for them to adjust and lengthen again.

True, I realized this after I posted. Still, considering she did all the 'testing' so to speak, finding out what was working (individual muscles) and what wasn't, that may have been ok. And now I am not really sure what she used for weight. I do think it was 5 pounds, but not positive. I will have to pay more attention in future. I was so worked up heading in to that PT session, and then realizing that it was OK and did not hurt, I missed a LOT for this first time around. The last inhome PT visit, I was at -1 extension and 85 flexion on my own, 90 with slight help. Three weeks later I was at -10 and 72/75. I really wish I hadn't had that 3 week gap- I am NOT a good coach to myself, I don't do the exercises here at home.