Exactly!
TKR Pain meds not working
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1ethal
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but why is it that the doctors and physical therapists are so much on a different page? At this point knee replacements have been around for a long time, why isn’t there a universal recovery method for everyone??
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Some thoughts...
I have had one surgery(shoulder) where the surgeon insisted I only use the PT he recommended because the other PTs in the practice simply didn't "get" shoulders. He's the exception. My other surgeons haven't had clue of the quality of area PTs, have no idea what exercise regimens different PTs espouse, and wouldn't be in a position to assess them. They are highly skilled technicians who do their best work while we're "asleep," and leave the rest to others.
Cultural attitudes about wellness: PTs in the USA, per our members, seem more aggressive, more likely to focus on "getting good numbers" by actively manipulating our knees, and more likely to ignore how long it takes muscles, tendons, and ligaments to heal than those in Great Britain or Australia. Overseas there's a greater understanding of convalescence, an essential concept largely disappeared from American medicine.
(A historical aside: PT as a formal profession here took off during the polio epidemic and a major focus of PT has been post stroke rehab. These models for approaching the patient were based on working aggressively with stretching and exercises for flaccid weakness/paralysis and contracting weakness/paralysis. Add in wartime and athletic injuries: young healthy very fit people with injuries, many of whom were expected "get back in the game (or outfit) ASAP." So the approach again was aggressive. You can see how an ethos of hurry up and rehab sets in.
The odd thing: in things like stroke and polio, there really can be a "window of opportunity" to avoid permanently crippling contractures by continually manipulating joints. I wonder if that's why so many PTs erroneously think knee patients have a window of opportunity and need hands on manipulation??)
I have had one surgery(shoulder) where the surgeon insisted I only use the PT he recommended because the other PTs in the practice simply didn't "get" shoulders. He's the exception. My other surgeons haven't had clue of the quality of area PTs, have no idea what exercise regimens different PTs espouse, and wouldn't be in a position to assess them. They are highly skilled technicians who do their best work while we're "asleep," and leave the rest to others.
Cultural attitudes about wellness: PTs in the USA, per our members, seem more aggressive, more likely to focus on "getting good numbers" by actively manipulating our knees, and more likely to ignore how long it takes muscles, tendons, and ligaments to heal than those in Great Britain or Australia. Overseas there's a greater understanding of convalescence, an essential concept largely disappeared from American medicine.
(A historical aside: PT as a formal profession here took off during the polio epidemic and a major focus of PT has been post stroke rehab. These models for approaching the patient were based on working aggressively with stretching and exercises for flaccid weakness/paralysis and contracting weakness/paralysis. Add in wartime and athletic injuries: young healthy very fit people with injuries, many of whom were expected "get back in the game (or outfit) ASAP." So the approach again was aggressive. You can see how an ethos of hurry up and rehab sets in.
The odd thing: in things like stroke and polio, there really can be a "window of opportunity" to avoid permanently crippling contractures by continually manipulating joints. I wonder if that's why so many PTs erroneously think knee patients have a window of opportunity and need hands on manipulation??)
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I think that is a good analogy. And everybody's baby ( knee) is different and everyone keeps telling you you are doing it wrong....And you keep meeting others whose baby sleeps through the night at 6 weeks ( knee bends fully/ is painfree/ back to playing tennis).
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I think @mendogal makes some very good and interesting points about rehab and also cultural differences. America is a very go-getting culture and maybe the UK ethos is a bit more relaxed generally.
The points about how rehabbing flaccid muscles after stroke or polio is very different is an excellent one. Injured tissues need to heal before you can stretch and strengthen them in a way that doesn't apply after neurological damage.
I do think that even though UK physios are generally gentler- they too can get wrong ideas circulating. The physio I saw in hospital warned me to not prop my knee on pillows to sleep- to avoid my leg getting stiff and not straightening properly. My surgeon was in the room behind her. He just winked at me and when she left- he said that was nonsense and to sleep any way I found comfortable.
The points about how rehabbing flaccid muscles after stroke or polio is very different is an excellent one. Injured tissues need to heal before you can stretch and strengthen them in a way that doesn't apply after neurological damage.
I do think that even though UK physios are generally gentler- they too can get wrong ideas circulating. The physio I saw in hospital warned me to not prop my knee on pillows to sleep- to avoid my leg getting stiff and not straightening properly. My surgeon was in the room behind her. He just winked at me and when she left- he said that was nonsense and to sleep any way I found comfortable.
1ethal
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Wow really interesting. Thank you all for the feedback. I think my first born baby (first knee replacement) is a needy child that isn’t going to sleep through the night for a while. It still bothers me that there is such a huge difference the at to rehab this properly. Thanks again as this information help’s tremendously in reducing anxiety throughout the process.
So it’s no wonder we are all so confused.
Just be reasonable with your rehab and keep common sense in mind.
1ethal
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Woke up this morning and started my exercises and I do have a little more flexion. I think patience and just having some peace of mind from this forum, not from my jerk doctor, has helped. Seriously, this forum needs to be offered to all patients before surgery to utilize throughout the process.
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I was blessed to have found Bonesmart six months before my TKR and read hundreds of posts beforehand, so I was ready to do it the Bonesmart way no matter what my doctor said! I also did not take formal PT, which my doctor was fine with. He knew I was recovering alone and had to take care of things. That was natural PT.
1ethal
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Is it normal when you first wake up from surgery to not have any ice on your knee? Or during your stay at the hospital that they do notice it at all? Or elevate your leg?
I’m going in for my second post op visit today and making a list of isssues I’ve had. I remember they didn’t ice my knee even once the entire time I was there including overnight. They also didn’t elevate my leg. They said they wanted it to try and stay straight, it there were no pillows or anything under my leg. This seems extremely odd to me now.
I’m going in for my second post op visit today and making a list of isssues I’ve had. I remember they didn’t ice my knee even once the entire time I was there including overnight. They also didn’t elevate my leg. They said they wanted it to try and stay straight, it there were no pillows or anything under my leg. This seems extremely odd to me now.
@1ethal Different hospitals have different protocols. From member reports, it appears that this isn't something routinely done, unless you are at a hospital that specializes in orthopedic surgery. Ice is something you can request -- and many folks do.
Be interested to read what your surgeon tells you.
Be interested to read what your surgeon tells you.
@1ethal
Not quite sure how I reply to OP on this forum...
Your story is so much like mine. In the hospital, I had no icing nor elevating. They wouldn't give me pain meds in the hospital because I have low blood pressure. So imagine just laying there in absolute agony, begging for relief. I almost wished I had died on the table!
My surgeon gave me an Rx for 5 mg oxycodone, one every 4-6 hours. Tylenol every 6 hours. None of that touched the pain at all. In the US, they are so stingy with pain meds because the doctors get reported if they prescribe "too many". I had a pacemaker implanted in August and there were no pain meds at all. Told me to take tylenol.
I am just at my month mark (TKR 11/12) and am not doing nearly as well as surgeon and PT want. Exactly 3 weeks from surgery, I woke up with only discomfort in my leg, not outright pain. That has been the highlight of my recovery. Having discomfort all day versus pain in the 7-8 range makes a huge difference in your life. I actually stopped the oxy and went to tylenol and a few tramadol I had from before my knee surgery. It was wonderful!
I cancelled my PT appointment today because on Wed they did too much and hurt me too much and I was back on the oxy instead of tylenol. So disappointing to be back on opioids. I found out that if I do not show improvement at every PT appointment, my insurance will not cover more PT. So there is a method to their madness in getting those better ROM numbers.
Please know you are not crazy nor too pain pill dependent. My surgeon originally said that of course they would give me more pain meds if I needed them. When I would run out and ask for more, they were not happy. And kept telling me I had to spread them out longer. When they're not really helping in the first place, how can you spread them out longer?
As far as freezing when using the ice machine, I have my clothes on, a huge sweater, 2 blankets and a heating pad on my back. Otherwise I couldn't stand the cold and shiver too much.
Take heart - it will get better especially at a month after surgery. Not by a huge amount, but you will be able to feel like you are making some progress. Follow the advice on this forum - they are so much more knowledgeable than our surgeons and physical therapists. Listen to your body. Don't become a member of the "did too much" club. Just not worth in.
Not quite sure how I reply to OP on this forum...
Your story is so much like mine. In the hospital, I had no icing nor elevating. They wouldn't give me pain meds in the hospital because I have low blood pressure. So imagine just laying there in absolute agony, begging for relief. I almost wished I had died on the table!
My surgeon gave me an Rx for 5 mg oxycodone, one every 4-6 hours. Tylenol every 6 hours. None of that touched the pain at all. In the US, they are so stingy with pain meds because the doctors get reported if they prescribe "too many". I had a pacemaker implanted in August and there were no pain meds at all. Told me to take tylenol.
I am just at my month mark (TKR 11/12) and am not doing nearly as well as surgeon and PT want. Exactly 3 weeks from surgery, I woke up with only discomfort in my leg, not outright pain. That has been the highlight of my recovery. Having discomfort all day versus pain in the 7-8 range makes a huge difference in your life. I actually stopped the oxy and went to tylenol and a few tramadol I had from before my knee surgery. It was wonderful!
I cancelled my PT appointment today because on Wed they did too much and hurt me too much and I was back on the oxy instead of tylenol. So disappointing to be back on opioids. I found out that if I do not show improvement at every PT appointment, my insurance will not cover more PT. So there is a method to their madness in getting those better ROM numbers.
Please know you are not crazy nor too pain pill dependent. My surgeon originally said that of course they would give me more pain meds if I needed them. When I would run out and ask for more, they were not happy. And kept telling me I had to spread them out longer. When they're not really helping in the first place, how can you spread them out longer?
As far as freezing when using the ice machine, I have my clothes on, a huge sweater, 2 blankets and a heating pad on my back. Otherwise I couldn't stand the cold and shiver too much.
Take heart - it will get better especially at a month after surgery. Not by a huge amount, but you will be able to feel like you are making some progress. Follow the advice on this forum - they are so much more knowledgeable than our surgeons and physical therapists. Listen to your body. Don't become a member of the "did too much" club. Just not worth in.
1ethal
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@westiemom
Thank you for this response! It was helpful to read.
I’ve been on micro doses of opiates for restless leg syndrome for the past 6 months. This has made the opiate pain pills almost completely ineffective. So, my surgeon is basically saying sorry for your luck. Pain is very manageable aside from right after PT. Then it sucks.
3 week post op appointment wasn’t good. Only 70 degrees of flexion and he wants more than 90 degrees. It If I can’t get there in a week or two he’s going to recommend manipulation - I really want to avoid this.
My surgery was the Wednesday before thanksgiving. They weren’t able to get pt started until the week after the holiday so that was delay number 1. Pain pills weren’t effective because I’ve been on opioid microdoses. So basically this process has been hell. My surgeon really doesn’t give a damn and doesn’t seem to want to help much. Just pushing through at this point knowing God got me.
Thank you for this response! It was helpful to read.
I’ve been on micro doses of opiates for restless leg syndrome for the past 6 months. This has made the opiate pain pills almost completely ineffective. So, my surgeon is basically saying sorry for your luck. Pain is very manageable aside from right after PT. Then it sucks.
3 week post op appointment wasn’t good. Only 70 degrees of flexion and he wants more than 90 degrees. It If I can’t get there in a week or two he’s going to recommend manipulation - I really want to avoid this.
My surgery was the Wednesday before thanksgiving. They weren’t able to get pt started until the week after the holiday so that was delay number 1. Pain pills weren’t effective because I’ve been on opioid microdoses. So basically this process has been hell. My surgeon really doesn’t give a damn and doesn’t seem to want to help much. Just pushing through at this point knowing God got me.
The doctor had me start PT in the hospital the afternoon of surgery. I had a nerve block so did okay. Second day without pain meds I refused the PT. Driving home for an hour laid out on the back seat of our SUV was absolute torture. Absolute pain 9-10 on the scale that night.
I didn't have another PT appointment till 2 weeks after my surgery since PT is so booked up around here. So for two weeks, I elevated, iced, dozed, and did very few exercises. My surgeon is young and he thinks everyone should be "textbook" in their healing. He was threatening MUA on my 2 week followup since I couldn't bend 90 degrees at 2 weeks.The pain is very real. And I read others' recoveries and they're on canes at one week and walking a mile and I get so depressed. I know that everyone heals differently, but it still makes me feel bad. And the ones who are off opioids in a week or two - I can't even wrap my head around that!
I am still not sure about my path forward. Thinking about giving up on PT and just doing exercises at home. No matter how much I hurt doing some of their exercises at PT, they don't seem to believe me and just keep saying "just a little more - you can do it". And I feel like a giant old failure cause I really can't do that little bit more.
I'm trying to stay positive, but it's really hard. Like my DH says, they can't force me to have the MUA. I can always say no. You're in the same position if they really push. But it's hard to tell a doctor who should know better than me that I'm refusing his advice.
Could they give you a different type of opioid than you having been taking that might make a difference? What about celebrex or gabapentin for nerve pain? Tramadol as a pain med is different than an opioid. I wish your doctor was more caring and would try harder to get you pain control. It's so difficult to even want to try when all you do is hurt. I totally understand!
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@westiemom You are NOT a failure. Your PT is failing you and your young surgeon has no clue how people actually recover. I'm glad your darling husband is on your side!
@1ethal
So how are you doing today? It's been about 3-1/2 weeks since surgery, right? Is your pain any better yet? I guess you can't talk to your doctor about different pain meds till tomorrow? I know my practice will not let the on call doctor prescribe any pain meds to any patient.
I am lucky on the pain meds myself. I have weaned myself down to tramadol unless PT hurts too much. I actually cancelled Friday's appointment cause I just couldn't face it. I did my at home exercises yesterday and will today too. Weather is too bad for outside walks, so am just circling around and around in my house.
I hope you are able to feel better this weekend. It is very disheartening right now at our stage in the trip. Keep your spirits up and know other people (at least this one!) is thinking about you and wishing you well.
So how are you doing today? It's been about 3-1/2 weeks since surgery, right? Is your pain any better yet? I guess you can't talk to your doctor about different pain meds till tomorrow? I know my practice will not let the on call doctor prescribe any pain meds to any patient.I am lucky on the pain meds myself. I have weaned myself down to tramadol unless PT hurts too much. I actually cancelled Friday's appointment cause I just couldn't face it. I did my at home exercises yesterday and will today too. Weather is too bad for outside walks, so am just circling around and around in my house.
I hope you are able to feel better this weekend. It is very disheartening right now at our stage in the trip. Keep your spirits up and know other people (at least this one!) is thinking about you and wishing you well.
1ethal
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@westiemom
Thank you. Pain is manageable most of the time outside of physical therapy. Afterwards it’s pretty rough. I had an appt this past week with my surgeon. He said he would not prescribe anything else so it’s Tylenol for me.
Starting outpatient physical therapy this week instead of in home therapy. I’m stuck at 70 degrees rom and he said possibly perform manipulation if that doesn’t improve over the next couple weeks. Really don’t want to do that. I’m doing my exercises religiously 3 times per day. Strength is good, but rom sucks. It’s just stuck. It won’t go further even when pushed or pulled. Def tired of this. I am able to drive a little ways but not too far. It would be nice to have e more pain relief after therapy and the end of the day is rough as well. Sleeping a little better. Just super frustrating that I’ve hit this wall and can’t get past 70 degrees rom.
Thank you. Pain is manageable most of the time outside of physical therapy. Afterwards it’s pretty rough. I had an appt this past week with my surgeon. He said he would not prescribe anything else so it’s Tylenol for me.
Starting outpatient physical therapy this week instead of in home therapy. I’m stuck at 70 degrees rom and he said possibly perform manipulation if that doesn’t improve over the next couple weeks. Really don’t want to do that. I’m doing my exercises religiously 3 times per day. Strength is good, but rom sucks. It’s just stuck. It won’t go further even when pushed or pulled. Def tired of this. I am able to drive a little ways but not too far. It would be nice to have e more pain relief after therapy and the end of the day is rough as well. Sleeping a little better. Just super frustrating that I’ve hit this wall and can’t get past 70 degrees rom.
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It really is early days and everyone is different. I really wouldn't try to force it too much by pushing and pulling as making things more sore and inflamed will not help. What was your ROM before surgery? Some very fit athletic types on here had/ have very tight muscles which I think can impede bend. Plus swelling/ inflammation definitely affects flexion and some people just swell more than others. I always was borderline hypermobile with very lax joints, which probably contributed to my valgus deformity and knee issues. But it meant that I had excellent ROM but my lax ligaments and not very strong muscles gave me some ongoing pain. It is swings and roundabouts- you have good strength which is a bonus.
1ethal
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being 42 and a life long athlete and current cyclist, I am in good shape and had no issues with rom before surgery. Pt has me doing as many leg beds as possible with a strap around my foot to pull it when I’m stuck. They do t want me pulling too hard, but enough to try and pull it further. It just doesn’t budge.
They also talked about using a dynasplint in the meantime as well? I think it’s a brace you out on that puts continuous force to bend you leg while you’re sleeping?
They also talked about using a dynasplint in the meantime as well? I think it’s a brace you out on that puts continuous force to bend you leg while you’re sleeping?
