TKR PT Mentioned the JAS

[TKR_Bill]

Hi folks, new member here. I had my left TKR on September 9th. I am 29 days post op and have experienced a rollercoaster of emotions, pain & depression over not "progressing" as "I" thought I should be. This all due to an excessive amount of reading many websites concerning TKR recover expectations.

I thought I had given up on the web searches (that only depressed me further) but yesterday I did a web search for "5 week post op TKR expectations." The fist hit was a link to this forum. I must say I have read & read & read so many threads here that they have really helped to settle my ragged nerves about not meeting what I believed to be "normal" expectations. With the help of this forum, I have been able to relax much and toss aside much of my erroneous thoughts. (I'm sure I'll still struggle a bit, but with the help of the "BoneSmarties" here I think I'm headed in a better direction.)

Here's my query:

Last week while at PT one of my therapists mentioned a device called the JAS or Joint Activation System. Today at therapy a different therapist mentioned that it might be "the way to go." This makes me believe this is the direction that want to take me ... I am currently at about 70 degrees flexion and 9 degrees extension. Every time go to PT and when I do my home PT, I aggravate things so much that I bump at a 7-8 on the relative pain scale. Then if I take my meds as scheduled with 1 or 2 "breakthrough", it takes 24 - 36 hours to come down to a reasonable 3-4 on the same scale, just to do it all over again. Has anybody on this forum heard about this device? (JAS) Or better yet, used one of these? It looks a little "high tech" Spanish Inquisition torture device to me. Thoughts?

 

[lovetocookandsew]

Hi, and welcome to Bonesmart! I haven't heard of the device, but maybe others here have and will weigh in. In the meantime, I'm leaving you your own copy of our PO reading-the articles aren't long and I think they're immensely helpful. My favorite was the activity progression guide which helped me to not to do too much, or too little, at any given point in recovery. Please keep us posted as you recover.

Knee Recovery: The Guidelines
1. Don’t worry: Your body will heal all by itself. Relax, let it, don't try and hurry it, don’t worry about any symptoms now, they are almost certainly temporary
2. Control discomfort:

​

rest​

elevate​

ice​

take your pain meds by prescription schedule (not when pain starts!)​

don't overwork.​

3. Do what you want to do BUT

​

a. If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you​

b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again.​

4. PT or exercise can be useful BUT take note of these

​

the BoneSmart view on exercise​

BoneSmart philosophy for sensible post op therapy​

5. At week 4 and after you should follow this

​

Activity progression for TKRs​

6. Access these pages on the website

​

Oral And Intravenous Pain Medications​

Wound Care In Hospital​

The Recovery articles:
The importance of managing pain after a TKR and the pain chart
Swollen and stiff knee: what causes it?
Energy drain for TKRs
Elevation is the key
Ice to control pain and swelling
Heel slides and how to do them properly
Chart representation of TKR recovery
Healing: how long does it take?

Post op blues is a reality - be prepared for it
Sleep deprivation is pretty much inevitable - but what causes it?

There are also some cautionary articles here
Myth busting: no pain, no gain
Myth busting: the "window of opportunity" in TKR
Myth busting: on getting addicted to pain meds


We try to keep the forum a positive and safe place for our members to talk about their questions or concerns and to report successes with their joint replacement surgery.
While members may create as many threads as they like in a majority of BoneSmart's forums, we ask that each member have only one recovery thread. This policy makes it easier to go back and review history before providing advice.

 

[Jockette]

Hi, Bill, and Welcome to Bonesmart!

I’m so glad what you’ve learned here has been helpful. That’s why we’re here!

Your knee is going to recover on its own timeframe, as you have found, not yours, not your PT’s and not your surgeon’s. It seems our medical team wants it to recover “yesterday.”

Personally, I think your knee just needs time to sort itself out. It’s only been 5 weeks since you had a surgery that caused a lot of trauma to your whole leg. This recovery takes an average of 52 weeks (one year) so you will definitely improve as time goes on.

You are dealing with a PT group that takes an aggressive approach and that’s why you have so much pain afterwards. The fact that they are suggesting this brace, and yes I’ve heard of it, tells me they believe in a “window of opportunity” in which to regain ROM, and the truth is, there is no window. I am 2.5 years post op and I’m still seeing improvements in ROM!

If it was me I would decline the brace and let my knee heal. I suggest you find another PT facility with a gentle approach, or, do your own rehab at home, but much more gently than you’ve been told to do. By now you probably have a good idea what works for you and I know you now know what doesn’t work for you.

We will be here for you!

 

[sistersinhim]

PT that leaves you in pain is not helpful PT. It's setting your recovery back because you have to recuperate from your PT days. Bad PT is much worse that no PT.

Many of us never took formal PT or did exercises. I am one of them. I had 11 knee surgeries, 2 of them kneecap removals and 1 tkr. Even after those I never took PT. But, I didn't just sit around and do nothing. I took care of myself, my house and yard as my knee allowed me to do. As I healed, I did more. But, my knee was always in control. This was enough therapy for me and would be for any tkr patient. All the awful pain of PT is so unnecessary.

All you have to do is use it in your daily living. Your knee knows how to rehab itself and doesn't need anyone telling it how. Just use it and it will come back like new. You have to be patient, though, it doesn't happen quickly. ADL,(activities of daily living), going to the bathroom, brushing your teeth and bathing, fixing a light meal, getting something to drink and or a snack, those kinds of things will be all the exercise your knee needs. If you just use it daily in your living, you can have a less painful recovery. We know what works, we've been there.

 

[Jamie]

We've had members who were prescribed the JAS, and frankly the results haven't been all that impressive. Plus they report it is bulky and uncomfortable.

As the others have mentioned to you, it appears at least part of your problem is overdoing the PT and exercising. I hope you read all those articles linked for you in the post above and take them to heart. You need to be doing lots of icing and elevating and fewer exercises until you can do them without having pain and swelling afterwards. As you've noticed, that is counterproductive.

I believe if you follow a more gentle approach to your activity and exercise for a couple of weeks plus ice at least 45 minutes 4-5 times a day, you'll see the results you're looking for. It's the swelling that's holding your bend back. As for extension, walking and stretching can get that for you. But it usually takes a bit longer to normalize than your bend.

Don't be in a hurry. You have plenty of time to get your full range of motion back.

 

[Celle]

Hi @TKR_Bill
As Jamie mentioned, the JAS splint doesn't do much to help and it can cause pain.

Jamie is correct - you have been asked to do more at PT than your new knee is ready for. PT can be uncomfortable, but it should never be painful.

Do remember this, always for your knee:

a. If it hurts, don't do it and don't allow anyone - especially a physical therapist (PT) - to do it to you​

b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again.​

​

It's only jut a month since you had major surgery on your knee. IT isn't lazy or unfit - it's wounded and it needs time and gentle treatment, so it can heal. Aggressive PT is bad for it, because it keeps those wounded tissues irritated and inflamed. That's counter-productive.

Your PT therapists have an agenda that is one-size-fits-all and it's not tailored to what your knee needs. They like to see your ROM (Range of Motion) numbers increase rapidly, because they then have good data to show, to prove that their ministrations have been effective.

They may also believe that you only have a certain amount of time to achieve good numbers. That's a fallacy, an old myth that should have died long ago.
There's no need to rush to get ROM (Range of Motion) because it can continue to improve for a year, or even much longer, after a knee replacement. There isn't any deadline you have to meet:
Myth busting: the "window of opportunity" in TKR

It's not exercising that gets you your ROM - it's time. Time to recover, time for swelling and pain to settle, and time to heal. Your knee is capable of achieving good ROM right from the start. Its ROM will gradually increase as your knee heals and the internal and external swelling decrease.

You are the only one with the right to say what happens to your knee, because it's your knee. While others, such as your PTs and your surgeon, may advise, you have the right to choose whether or not to accept their advice.

So, for the sake of your knee - and of your own comfort - tell your PTs that you will no longer do any exercise that hurt, and you won't exercise an excessive amount. You have the right to do that.
Saying no to therapy - am I allowed to?

If you can. work with your therapist, to do a more gentle type of exercise. If they can't accept your wishes, either find another PT clinic or stop going at all, and then exercise gently at home.
Many of us have re-habbed a new knee without going to PT, but just by letting our activities of daily living be our therapy. Simply walking is one of the best forms of PT for a new knee.

 

[TKR_Bill]

Hi folks. Thanks for all the kind replies and information. I wanted to reply to each post, but I was confused on how to use the reply option. I started out by pressing “Quote This Message”, but I didn’t really mean to quote each message. So I deleted all the “quoted” message in the reply box and thought I’d try this. (Pardon my forum posting ignorance.)

Anyway, I truly am grateful for all the love I’ve felt by the responses. Thanks again.

 

[Pumpkin]

You are doing fine with your posting, once someone posts in your thread they will be notified when there are new posts, no need to quote. Just scoot down to the bottom of the page and start typing in the rectangle next to your avatar to post.

Here are some links to gentle activities you can use for ROM:
Heel slides and how to do them and Extension: how to estimate it and ways to improve it .

Members have reported the JAS is cumbersome and uncomfortable.

 

[Jockette]

You replied just fine.

It is not necessary to quote each message to reply, and actually we would prefer you didn’t, unless there is a specific part you want to quote. In that case, highlight the line you want, a link will pop up, choose “+quote” and only what you highlighted will be quoted. Go to the reply box and tap “insert quotes” and it will pop it into the reply box, like this:

Hi folks. Thanks for all the kind replies and information.

Unnecessary fully quoted messages take up a lot of space, and when the staff is reading back over your information, we don’t want to have to read over these long quotes to find your history that we need.

Just scroll down to the reply box and start typing, just like you did. You’ll get the hang of it.

 

[TKR_Bill]

Just scoot down to the bottom of the page and start typing in the rectangle next to your avatar to post.

Just scroll down to the reply box and start typing, just like you did. You’ll get the hang of it.

Thanks Pumpkin & Jockette . I think I have it.

 

[TKR_Bill]

Good evening folks. I over did it today. Felt great this morning, but ended up doing way more than I should have. I’m finding it so hard gauging how much I can do each day. I used to be Superman, but now being up walking around for 15 minutes does me in. So it’s Rest, Ice, Compression & Elevation often. I fool myself because I feel better after icing, so I do a little more. Then in the late afternoon I hit a wall. (Must learn to listen to my body better.)

No real question for tonight, just wanting folks to know where I’m at. I have a PT appointment tomorrow. To be honest I have a bit trepidation over it, although I’m thankful they’ve been fairly gentle with me. The JAS has not been “officially” recommended, just casually mentioned. It will be interesting to see what they say tomorrow. I haven’t decided how I feel about it yet. I’ve heard some good and some “ok” about it, but nothing yet that screams at me to run from it. If it helps and doesn’t hurt me, why not? Especially if it will increase my ROM and extension. We’ll see.

On another note, I bought a recumbent bike yesterday. Found it on CL for $275. Thought it was a good buy. (Shwinn 230) I have some friends who will set it up for me tomorrow. (So very thankful for friends and family!) Looking forward to going “back and forth” on it.

 

[Celle]

The JAS has not been “officially” recommended, just casually mentioned. It will be interesting to see what they say tomorrow. I haven’t decided how I feel about it yet. I’ve heard some good and some “ok” about it, but nothing yet that screams at me to run from it. If it helps and doesn’t hurt me, why not? Especially if it will increase my ROM and extension. We’ll see.

It's only just over a month since you had surgery. It's completely inappropriate for your PTs to be even mentioning the JAS splint. If it is used, it is normally for people who have a seriously delayed increase in ROM.

For you, it isn't necessary. Your ROM is going to increase naturally, as time passes and your knee heals and becomes less swollen. You can help this process by giving your knee enough rest now, so do try not to consistently overdo your activity.
This recovery is a year-long project. In terms of a race, it's a marathon, not a sprint. You need to pace yourself.

 

[TKR_Bill]

Good morning Bonesmarties. I really appreciated reading many different post in this forum. As it turned out, I did not get the JAS Friday. For the most part I really like my therapy people, but admittedly they do hurt me. I’m actually going to talk to them about that today. After therapy Friday it took a good 36 hours for me to recover. So the weekend was not a real great weekend. I honestly didn’t think the PT did a whole lot at my last session, but when it takes 36 to 48 hours to recover they apparently did. I also think I’m trying to play both cards. I’m encouraged by the hope I read here at Bonesmart but would like to incorporate some of the therapy in the plan. But I’m beginning to believe they can’t really co-exist.

On a positive note, even though I don’t have a lot of ROM yet and given the rough weekend, I was able to get on my new recumbent bike. Of course I’m just going back-and-forth very lightly. My wife actually thinks she’s noticed an increase in range of motion because of the bike already. I just know that it felt pretty good and didn’t hurt. I am taking it very easy on the bike. I actually think that’s done more for me in ROM then the therapy so far.

Wish me luck as I talk frankly with my therapy folks today. I’ve had a 12 year relationship with these folks and as I live in a small town I really don’t want to damage my relationship with them. But I also don’t wanna have constant pain every time I go to PT. They have helped me a lot with other issues, but it seems real rough this time around.

 

[TKR_Bill]

Hi folks. Just wanted to give an update on where I’m at. At my last PT appointment this past Thursday (October 17), I could tell they were disappointed in my progress. Even though I have felt they have not been too aggressive, it still takes me 36 to 48 hours to recover after a session. But after reading, and reading posts in this forum, I’ve decided to go with the advice I hear on BoneSmart.org. It just makes sense to not terrorize a portion of your body that is already suffering the trauma of a major surgery. I really subscribe to the idea of letting time heal my wounds then begin to rebuild the new knee.

I have my six week postop appointment this coming Tuesday with my OS. I’m not really sure what the surgeon will have to say, but I will be careful not to accept aggressive rehab. Thank you all for the repeated encouragement of letting time heal my knee before the long work of strengthening.

I read in another post somewhere, (I forgot to quote it) that it was suggested by one of the forum advisers to list other surgeries and conditions which should be considered in my recovery plan. I don’t want to over do it but if it helps to understand my struggle, the advice and encouragement would be more helpful than just general advice.

I have suffered with chronic pain from OA for the past 18 years. It started with the lower back (L5-S1), add the neck (C2-C5), both knees with the left one being the worst, as well as both ankles showing significant arthritis In the last 2 years. And lastly, for 8 weeks before my TKR I’ve dealt with Posterior tibialis insufficiency of my right ankle. (my good leg)

I had a spinal fusion of L5-S1 in 2009. That relieved the majority of pain for the following 3 years. But slowly the pain levels began to climb, the culprit being a compromise of L4 and L5, the neck and the left knee deteriorating rapidly. I refused to have a second fusion, opting for meds to mitigate my pain. Finally, together with my wife we decided I was too young to be so decrepit. I began saying that 58 was the new 90. You’re only as old as you feel, and I felt 90! So we begin to investigate which body part we should begin with which led me to this TKR. After cortisone injections and HA injections failed, it was time.

Before the TKA (Sept. 9, 2019) I was taking 4, 10mg oxycodone per day to keep pain levels around a 4 on the relative pain scale. (here in the US, in case it’s different elsewhere) I could function, but I didn’t do anything outside of what I absolutely had to do. I spoke with the OS about pain management post op considering what I had been taking. I also spoke with my Pain Specialist about it. They assured me they would take care of me and give me adequate meds for pain control. Well the ball got dropped and I had horrible pain the first 10 days follow the TKR which I feel significantly slowed my healing progress Through many phone conversations, my wife finally got the docs to get me enough pain meds to control the pain. Six 10mg oxycodone a day (1 every 4 hours), 2mg dilaudid as needed for breakthrough pain, 5mg baclofen (a muscle relaxant 3x daily). 6 weeks post op I am taking 5, 10mg oxycodone per day and the baclofen, breakthrough meds as needed. (Usually before a PT session) I tried to go to 4 oxycodone last week but the pain levels rose too high.

Right now the back of my operated thigh is so very sore that I can’t hardly tolerate sitting on it for any length of time. I think the tourniquet has something to do with it, but I recognize the siadic pain as I’ve had it for a long time. As long as the pressure is distribute well I can sit in my recliner and lay on my bed. Most chairs however hit the back of the thigh in the wrong place and I go downhill fast. My lower back and my neck, along with my knee are about equal contributors to my pain at this time, but the knee wins most of the time. Am I right to think that if I had fairly significant siadic pain before TKR, when the knee quits screaming, it would emerge again? Does that change the approach to my TKR recovery, meaning even a longer road? Should I mention these concerns again to my OS at my 6 week post op appointment this week? Am I making any sense?

 

[Jaycey]

Sorry you are suffering with sciatic pain. I have chronic lower back issues and do sympathise!

Am I right to think that if I had fairly significant siadic pain before TKR, when the knee quits screaming, it would emerge again?

After my first THR I had major sciatic pain flare. Post any joint replacement you will be walking differently - carrying your weight differently. Its bound to impact any spinal issues.

Does that change the approach to my TKR recovery, meaning even a longer road?

Not necessarily but every recovery is different. There is no real timeframe for all this. Your knee is now dictating how long it will take to recover.

Should I mention these concerns again to my OS at my 6 week post op appointment this week?

Yes, but please remember - 6 weeks out is still very early days. This recovery can take a year or more.

 

[luvcats]

Our stories have a number of similarities.

Well the ball got dropped and I had horrible pain the first 10 days follow the TKR which I feel significantly slowed my healing progress

I believe you are right. For my first surgery they really ignored the fact that I'd been on Tramadol for more than a year and would therefore have a tolerance. I was sent home with a standard small dose of oxycodone and they were very unsympathetic to my situation at the OS office. It wasn't until I saw my pain specialist after surgery that I finally got what I needed. Fortunately, we arranged an appointment just before my second surgery and she provided my prescriptions for that. It was a completely different experience.

I think the tourniquet has something to do with it, but I recognize the sciatic pain as I’ve had it for a long time.

I have had problems with both of these things. After my first replacement I swear the pain and cramping in my thigh was worse than the pain from the knee. Part of that was the tourniquet, but some of it was just from realigning the muscles which then had to learn a whole new way to most, and they were very resentful!

Before my second surgery I carefully went to the chiropractor and had my hips aligned so I wouldn't have sciatic issues. But wouldn't you know it, when I woke up after, my right hip was almost as mad as my new knee. They obviously tweaked something manhandling me during the surgery. I had to wait about 6 weeks to get back to the chiropractor. Are you icing your glute where the periformis runs? I get a lot of relief from that. I also sometimes use an arnica cream applied directly to my bum where it joins the leg, which is where I primarily feel my pain. Regular application of magnesium oil to the hip and leg is my other solution. Magnesium oil is a natural muscle relaxant and it helps me a lot with sciatica and it was very helpful when my thigh was cramping.

Good luck finding some relief. The knee is quite enough to deal with without sciatica and muscle cramps on top of it.

 

[TKR_Bill]

Sorry you are suffering with sciatic pain. I have chronic lower back issues and do sympathise!

Thank you so much @Jaycey. It is nice to know someone else has experienced similar issues.

Are you icing your glute where the periformis runs? I get a lot of relief from that. I also sometimes use an arnica cream applied directly to my bum where it joins the leg, which is where I primarily feel my pain. Regular application of magnesium oil to the hip and leg is my other solution. Magnesium oil is a natural muscle relaxant and it helps me a lot with sciatica and it was very helpful when my thigh was cramping.

@luvcats I have been icing the glute a bit, but I probably should be doing it a bunch more. I have not heard of arnica cream nor magnesium oil. I’ll have to research those a bit and give them a try. Thank you for the encouragement!

 

[Rockgirl4]

I'm just seeing your thread but wanted to say I used one of the braces/splints back in 2016 following a different type of invasive knee surgery. My particular surgeon suggested the Dynasplint, and I used one for extension and a separate one for extension. Honestly, they were both a waste of time and money. The one for extension HURT!!! I was told to use it at night while sleeping, but I couldn't last 1 hour in that thing.

I was also being subjected to over-aggressive PT though, but I didn't know better back then. I had my right TKR this past May, and thankfully I'd learned enough about my body and it's tendency towards rebound swelling to know any aggressive PT is not good for my body. I swell a lot, I swell forever, and I'm a chronically slow healer. I've had 11 knee surgeries from age 25-46, some of which were easy arthroscopies, and 5 of which were major with long recovery/rehabs. All proved I just don't bounce back as fast as others, and my knee needs more babying to limit swelling. Otherwise my range of motion (especially flexion) takes forever to come back.

I think you're doing a good job of figuring out what works best for you, but I know it's hard to object to PTs you have a good relationship with. I had one PT clinic and therapist who helped me significantly, but over time, he broke my trust, hurt me on numerous occasions, and would NOT listen/respect my wishes. I finally had to dump them. My sanity AND range of motion thank me to this day.

---Lisa

 

[TKR_Bill]

@Rockgirl4 - Thank you for this response. You've touched on 2 big areas of concern for me. As far as the brace, the OS has not given the OK for it, basically ignoring my PT's suggestions to Him. In fact I just saw my OS last Tuesday (6 weeks post) and he was concerned about the lack of ROM for flexion but encouraged for the extension. (Currently around a 70° for flexion and about 7° for extension. He seemed much much concerned about the amount of swelling. So when I read this:

I swell a lot, I swell forever, and I'm a chronically slow healer.

I was very encouraged. I mean I had read enough about what to expect for swelling, but my interpretation to all I read was way off. I've begun thinking that I must be a freak of sorts, because still in my mind, I am not healing as I should. It seems that if I look at or think about my knee, it knows and just starts swelling to prove it's in charge. Especially at night.

The OS told me to stop PT and do light stuff at home (ADL's, although he didn't call them that) and to use my recumbent bike 3x per day for 3 minutes or less with non aggressive movements, meaning to not cause pain. He also put me on Prednisone once a day to help with the swelling, but as of yet (5 days) I'm not noticing any real help. I ice and Ice & Elevate at least 6x a day and that does help somewhat, but I'm a baby when it comes to cold, yet I buck up a do it because I get relief. I go back to see my OS on November 6th for another follow-up.

I would love to know more about your approach to mitigating swelling, because I think it may help me. Every time the swelling subsides I can bend my knee a little bit more and I feel so much better. Thanks again for joining my recovery thread and sharing your experiences.

 

[Jockette]

The OS told me to stop PT and do light stuff at home (ADL's, although he didn't call them that) and to use my recumbent bike 3x per day for 3 minutes or less with non aggressive movements, meaning to not cause pain.

I agree with your OS. You are very blessed to have an OS with this opinion. Too many of us have the opposite. Time and gentle treatment will heal your knee far better than pushing and forcing it to do something before it’s ready.

Every time the swelling subsides I can bend my knee a little bit more and I feel so much better.

Proof that swelling is the issue, and in time it will settle down.