TKR LTKR nearly 6 weeks out- Questions and concerns about PT

karenl

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Hello, you are being super hard on yourself. My advice would be to get another physical therapist soon. I am at six months and did lose a little progress when I just got so tired and let it rest. Quad muscles have a lot to do with pain and healing. Keep working on quads. I massage where my scar is with bio oil almost every day and it does break up scar tissue. Keep doing at home exercises and use exercise bike forward and backward a few times a day. While therapy hurts it should not hurt as much as you state. Change therapist asap!!!! Slow but steady and yes looks like a year before total recovery. I just started 2nd round of therapy and it is helping. Dry needling working to help loosen quad. You are at beginning of recovery so be kind to yourself and know this takes a while.
 

Annie5

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Hello everyone! First time posting, but I’ve been scouring this site for a few weeks for answers and advice. Had my LTKR on May 25, 2022 - so I’m almost 6 weeks post op.
Hi tweety bird, you are only a very short step on your journey so try to remember that. I haven’t had Physiotherapy and don’t need anyone pushing my body harder than it wants to go. Please be gentle on yourself and use your own intuition on whether or not you need extra help. My knee from 8 weeks ago is doing really well but I have a lot of pain on my thigh which is fairly numb but feels like I’ve got broken glass underneath the skin. It’s very painful but the consultant says it’s where the tourniquet was and I have fibromyalgia and this is reacting now. He’s seen it before. Sometimes I can’t bear any clothes on it so know how you feel, it’s awful! Maybe yours is a similar thing or not but I know how it feels. Take care of yourself and be gentle.
 
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Arjay

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Just anecdotal, but…..my spouse had torn quadriceps repair (more than 10 years ago). His surgeon was part of a practice that were team docs for an NFL franchise (so, pretty knowledgeable/respected). I have always remembered that doc's attitude towards PT - (not against it, spouse did do a regimen) - but he was clear in his opinion that many PTs are way too aggressive.
 

Seatides

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"One more question - can anyone guide me to any studies or info that supports the Bonesmart approach to therapy? Gentle therapy makes SO much sense to me- why aggravate an already inflamed joint with intense therapy that creates more inflammation? But - I think that traditional PT is geared toward an aggressive approach to TKR rehab. I’ve found it difficult to find any studies/opinions supporting a more 'hands off' approach."

Hi @tweetybird! I'm a little late to this conversation, but as others have posted, I too get extremely upset when reading these monstrous PT horror stories. It happened to me with my first knee, and with my second knee, I'm trying to be patient with this PT Assistant who keeps repeating cliches about how of course there's going to be some pain, and that the solution to stiffness and swelling is to exercise. She's not hurting me, but she's not hearing me, if you know what I mean!

But what I wanted to comment on is your very reasonable question about the supporting documentation for the BoneSmart approach. When I had my first knee done almost 3 years ago, I searched everywhere for professional PT practice guidelines that supported the painful "aggressive" approach. I'm a medical editor, so I searched PubMed and the PT and ortho societies' websites for guidelines. There is NOTHING! I found plenty of articles that said, "We really need to develop some standardized guidelines for post-TKR rehab," but they've been saying that for years!

This time around I've been searching again and, if anything, a couple of the newer references suggest that exercising at home is just as effective as formal PT. This is more like support for the BS approach! But I'm in bed typing on my cell phone, and a couple of articles I saved are downstairs on my laptop. So I'll post them tomorrow.
 
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Seatides

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This is information about one article I found recently on this topic. Below is the conclusion of the article, published in 2019 in the Clinical Orthopedics and Related Research journal of the Association of Bone and Joint Surgeons, entitled "2018 John N. Insall Award: Recovery of Knee Flexion With Unsupervised Home Exercise Is Not Inferior to Outpatient Physical Therapy After TKA: A Randomized Trial."

"In conclusion, the results of this study suggest that unsupervised home exercise is an effective and adequate rehabilitation strategy for selected patients undergoing primary, unilateral TKA. Most patients were able to follow the home-based exercise program to completion and avoid costly physiotherapy services while achieving noninferior functional results. Importantly, a delayed recovery protocol is necessary and can provide a means for early intervention for those struggling to meet minimum recovery milestones. With this limitation in mind, it may be time to reconsider the current practice of routinely prescribing outpatient PT after discharge subsequent to primary, unilateral TKA."

The free full text of this article is available at this link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6345292/
 
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Jamie

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@Seatides, thank you so much for the reference and the detailed link information. You're correct in noticing that there are precious few studies out there to offer opinions on therapy and many therapists still go with the aggressive route. But, interestingly enough, there is starting to be some change on the surgeon's end. As an example, we have a group of surgeons we work with for BoneSmart and one our doctors recently mentioned that he has changed his approach to more closely align with what we recommend on the forum....an initial period of healing time for the joint (this applies to any joint replacement) where the patient is concentrating on just being mobile the first week or so with gentle bending and stretching every few hours. This is followed by a gradual increase in activity and exercise as the patient can tolerate without pain or swelling.

I have noticed this change in approach from the surgeons coincides with the more widespread use of multimodal pain medication that allows a patient to be relatively pain free for the first couple of days following surgery. Rather than have them jump into a therapy program that could cause inflammation and swelling, it may be the surgeons have seen the more positive results of allowing a more gradual approach. It used to be that pain and swelling were a "given" after joint replacement surgery. Not so these days. The pain medications injected into the incision before closing and used as part of the anesthetic protocols allows tissue to heal without much less inflammation in these first critical days.

I'm a good example. I just had my right hip replaced on August 23rd. Unfortunately because of arthritis in my lower spine, I was not able to have the spinal anesthetic and had to go with a general. But even with that, my surgeon's techniques were such that I had no bruising, very little swelling, and consequently my pain was manageable with Tramadol and Tylenol even right out of surgery. This is so much different that my previous joint replacements where hydrocodone was needed and pain was more difficult to keep in line.

Hopefully at some point this topic will be studied more so there can be scientific support for our approach. But in the meantime, we'll be going with what we've seen work for thousands of joint replacement patients.

Please feel free to post other pertinent links you find. Our staff is so busy with members that they just don't have time to research all the material that's out there.
 

Seatides

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@Jamie, this is so interesting! So you're observing (in yourself too!) that as surgeons are switching over to a more multimodal (and more effective) pain management approach, they're beginning to see that painful, aggressive PT early on is counterproductive. So presumably the surgeons with whom BoneSmart works (or at least, the one you mention) communicates this change in his thinking to the physical therapists (e.g., maybe he describes the kind of PT he wants in his PT referral)? I'm just wondering if/when/how this evolving thinking will reach the PTs.

So I just went to search this again and found two clinical practice guidelines listed at the website of the American Physical Therapy Association: 1) Physical Therapist Management of Total Knee Arthroplasty, dated September 2020 and 2) Joint Replacement (Primary): Hip, Knee and Shoulder, dated June 2020 (this was actually created by the UK's National Institute for Health and Care Excellence [NICE]).

The TKA guideline is 45 pages and I've only skimmed it so far. It was created by a work group consisting of 10 PTs, 1 orthopedic surgeon, 1 nurse, and 1 consumer. But my initial impression is that it was created to document what the PTs consider "standard of care," whether there's evidence to support those practices or not.

For example, for "Postoperative Knee ROM Exercise," it says, "It is the consensus of the work group that physical therapists should engage and teach patients to implement passive, active assistive, (my emphasis) and active ROM exercises for the involved knee following TKA. Evidence Quality: Insufficient; Recommendation Strength: Best Practice." I'm highlighting "active assistive" because that's the type of therapy in which the PT provides "support" -- i.e., makes your joint do what you can't do on your own. Interestingly, though, I searched the document and can't find anything in it about flexion and extension goals that must be met within a certain timeframe -- i.e., the "window of opportunity" (this term doesn't appear in the document).

The TKA document is at this link: https://pubmed.ncbi.nlm.nih.gov/32542403/ (free full text). The joint replacement one (which I haven't looked at yet) is here: https://pubmed.ncbi.nlm.nih.gov/32881469/. @Jamie, what do you (and other BoneSmarties) think?
 
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Jamie

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Thank you for providing another couple of good studies for review. I took a look at both of them and found information I can incorporate into our ongoing update of BoneSmart Library material. In particular, the Oxford study does support what we believe to be true. Although there can be a "standard of care" for all joint replacement patients, it must be applied along with consideration of a wide variety of factors that might alter a therapy approach for individual patients. I noticed that, even though one section of the document mentioned what we consider to be more aggressive early therapy, it was advised only when the therapist considered it's impact on swelling and pain that might take place. This is the key factor that I believe so many people miss when talking about an aggressive versus a more gentle approach. You'll find people that believe it's okay for patients to try and push through pain. But in reality, this only results in additional pain and swelling and potentially a slower recovery for many people. What we do see is that there is a small subset of patients that can implement aggressive therapy and do just fine. It's all about listening to your body and responding appropriately to the signals (pain and swelling) that indicate this approach is not good for that particular patient.

I appreciate your assistance in locating these articles.
 

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