TKR Recovery not the cake walk I thought

[mgdurand1]

Good for you, Mgdurand1! Sounds like you are doing quite well. Please don't rush it. Take your time and take it one day at a time. Take it from a hard head! I have one step forward then one step back because I think that I can do more than I actually can. I am four weeks and one day on this side of surgery.

Thank you so much! I have definitely scaled back from that first week ("I can do this! All I have to do is work more than they told me to and do each exercise long after it hurt real bad!") and the improvement has been steady and noticeable. I think the best preparation was in my head, and my wife was the real teacher there. Commit to work hard, don't overwork, let your pain be a guide, look past the setbacks to the day when you will not immediately think about your having an artificial knee, and look forward to going to back to work first for a few hours a day and then full time (knowing there will be pain and swelling to deal with). This is so much more involved a recovery process than I thought it would be, but the encouragement here has been so very helpful - I hope my successes (as well as my backslides) will be of help to others here as well. Thanks again.

 

[Celle]

OK. I've just got to say it!
mgdurand1 and @50yearold :

• You are both expecting too much, too soon! Patience is your friend!
• You are both working too much and too hard and that is why your knees are swelling and also why you are worn out.
• All this enthusiastic exercise at such an early stage is just a dead waste of time and effort. Bending will come, once the swelling settles down. Concentrate on reducing the swelling, rather than pushing yourself to exhaustion and your knee to further irritation. All you need to do is gentle stretching and bending. No exhausting PT sessions.
• You cannot make your knee bend by doing lots of PT at this early stage and you won't lose the ability to bend that knee if you don't do the PT. And you can't make it heal faster, either.
• I don't care how many PhDs your physio and your doctors have - what they advise you is just "The American Way". If you and they lived in the UK or in New Zealand, they would be telling you different!
• People in the UK and NZ recover with minimal routine PT - or even none at all. They just do simple exercises, which they follow from a printed sheet they are given. Apart from that, their daily living activities are all they need. And, guess what? Their results are just as good as for people in the USA ( and sometimes even better). I had a grand total of 3, short PT sessions. My ROM is 0 and 125.

Relax, give your knee time to heal and recover from major surgery before you send it to boot camp! It isn't an unfit knee that needs to be licked back into shape. It is a wounded knee. Treat it kindly!

 

[mgdurand1]

OK. I've just got to say it!
mgdurand1 and @50yearold :

• You are both expecting too much, too soon! Patience is your friend!
• You are both working too much and too hard and that is why your knees are swelling and also why you are worn out.
• All this enthusiastic exercise at such an early stage is just a dead waste of time and effort. Bending will come, once the swelling settles down. Concentrate on reducing the swelling, rather than pushing yourself to exhaustion and your knee to further irritation. All you need to do is gentle stretching and bending. No exhausting PT sessions.
• You cannot make your knee bend by doing lots of PT at this early stage and you won't lose the ability to bend that knee if you don't do the PT. And you can't make it heal faster, either.
• I don't care how many PhDs your physio and your doctors have - what they advise you is just "The American Way". If you and they lived in the UK or in New Zealand, they would be telling you different!
• People in the UK and NZ recover with minimal routine PT - or even none at all. They just do simple exercises, which they follow from a printed sheet they are given. Apart from that, their daily living activities are all they need. And, guess what? Their results are just as good as for people in the USA ( and sometimes even better). I had a grand total of 3, short PT sessions. My ROM is 0 and 125.

Relax, give your knee time to heal and recover from major surgery before you send it to boot camp! It isn't an unfit knee that needs to be licked back into shape. It is a wounded knee. Treat it kindly!

________________

Hi, Celle. I appreciate your comments and your personal experience, but you are not, I think, reading my complete thread comments. The heavy PT was exactly what I was doing for a week. Too much work - too much pain. After that, my wife (an RN) and my PT advised me to slow down and not exercise through the intense pain. I am doing that and my recovery is progressing exactly as was predicted by my orthopod. My pain is very controllable when not in PT mode and when doing PT is controlled by the medication which I take an hour before. My gauge is my pain. I will not overdo it and stop when the pain is such that I know it is not productive. I have two friends with TKAs and the same surgeon and their progress was pretty similar to mine through this point, except mine is a bit better to date (flexion and extension, pain, walking). One fellow was back full time at 6 weeks after a single and the other was back in 8 weeks after having both knees replaced. We are not in the heavy manual labor work arena as I noted earlier. I am very lucky as I can pretty much take all the time I need before going back in to work, but I also know that want to get back as early as is reasonable! I think the key thing you need to remember is that no two people are alike, and we each have to use our heads as well as our knees to get to where we need to be. Some will heal slower than others. Some will heal faster than others. I do have a friend in the UK who did very little PT and he has a very difficult time walking years after the surgery. My knee swelled the day I did no PT. Swelling is a normal reaction to trauma to tissue. I agree with you that too much too soon will aggravate the swelling and that swelling inhibits movement. One thing I did not see in your response (maybe you have mentioned it in other postings) is cryotherapy. It has been a major help to me in keeping the swelling under control. We do this at least 5 times a day for about 15-20 minutes. The exercising I do actually makes the pain much less and 2 and 1/2 weeks ago I would have never thought I would be at this stage. While doctors and physical therapists certainly do not know everything and we are the ultimate boss in our recovery I believe that we need to trust their professional judgment. If I did not then I would go hire someone else. Thanks for the thoughtful comments and continued good luck to you and good luck to all as we go through this tunnel. There is a light at the end!

 

[Celle]

________________

Hi, Celle. I appreciate your comments and your personal experience, but you are not, I think, reading my complete thread comments. The heavy PT was exactly what I was doing for a week. Too much work - too much pain. After that, my wife (an RN) and my PT advised me to slow down and not exercise through the intense pain. I am doing that and my recovery is progressing exactly as was predicted by my orthopod. My pain is very controllable when not in PT mode and when doing PT is controlled by the medication which I take an hour before. My gauge is my pain. I will not overdo it and stop when the pain is such that I know it is not productive. I have two friends with TKAs and the same surgeon and their progress was pretty similar to mine through this point, except mine is a bit better to date (flexion and extension, pain, walking). One fellow was back full time at 6 weeks after a single and the other was back in 8 weeks after having both knees replaced. We are not in the heavy manual labor work arena as I noted earlier. I am very lucky as I can pretty much take all the time I need before going back in to work, but I also know that want to get back as early as is reasonable! I think the key thing you need to remember is that no two people are alike, and we each have to use our heads as well as our knees to get to where we need to be. Some will heal slower than others. Some will heal faster than others. I do have a friend in the UK who did very little PT and he has a very difficult time walking years after the surgery. My knee swelled the day I did no PT. Swelling is a normal reaction to trauma to tissue. I agree with you that too much too soon will aggravate the swelling and that swelling inhibits movement. One thing I did not see in your response (maybe you have mentioned it in other postings) is cryotherapy. It has been a major help to me in keeping the swelling under control. We do this at least 5 times a day for about 15-20 minutes. The exercising I do actually makes the pain much less and 2 and 1/2 weeks ago I would have never thought I would be at this stage. While doctors and physical therapists certainly do not know everything and we are the ultimate boss in our recovery I believe that we need to trust their professional judgment. If I did not then I would go hire someone else. Thanks for the thoughtful comments and continued good luck to you and good luck to all as we go through this tunnel. There is a light at the end!

Hi Mike,

I did read all of your thread, especially all of your posts, before writing what I did. I know that you have cut back, but the overwhelming impression I get from you is that you still think you can work at increasing the speed of your recovery. Several people have tried to tell you, perhaps less bluntly than I did, that it doesn't work that way. The knee is in charge here and it will recover in its own, sweet time.

If you stick around for a while, time and again you will see threads from people who are frustrated because they have worked hard and are not getting the results they hoped for. In almost every case, cutting back on activity and concentrating on reducing swelling brings about the improvement they were hoping for.

While we're talking about reducing swelling, I didn't go into details because my post was already long, but Rest, Ice (call it cryotherapy if you want), Elevation (toes above your nose) and taking your pain medications by the clock are all paramount. There is no need to limit cryotherapy to 15-20 minutes at a time. You can't do any harm by cooling your knee for longer, provided that you make sure to put a cloth or something similar between your skin and the ice pack.

I see that you've already reduced your medications. It's a bit early for that but that's your choice. However, it is not a good idea to take pain relief to dull pain during physiotherapy, as you are doing. That pain you would feel without the medication is a warning sign. By masking that pain, you are preventing your knee from telling you when to say "Enough", so you may unwittingly be pushing too much.

The day that your knee swelled when you did no PT - was that the day you sat with your sick friend? Do you think that sitting around, without elevating or icing your knee, might have had a little something to do with the swelling?

I do know that no two people (and no two knees) heal the same. I've had 2 knee replacements myself and they felt quite different.

Sorry if I come across as a bit bossy. I'm an ex-nurse, and bossiness is an occasional occupational hazard!

Best wishes!

 

[referee54]

do know that no two people (and no two knees) heal the same. I've had 2 knee replacements myself and they felt quite different.

I had both of mine done at the same time, and my right knee was my "problem child.":

 

[mgdurand1]

Hi Mike,

I did read all of your thread, especially all of your posts, before writing what I did. I know that you have cut back, but the overwhelming impression I get from you is that you still think you can work at increasing the speed of your recovery. Several people have tried to tell you, perhaps less bluntly than I did, that it doesn't work that way. The knee is in charge here and it will recover in its own, sweet time.

If you stick around for a while, time and again you will see threads from people who are frustrated because they have worked hard and are not getting the results they hoped for. In almost every case, cutting back on activity and concentrating on reducing swelling brings about the improvement they were hoping for.

While we're talking about reducing swelling, I didn't go into details because my post was already long, but Rest, Ice (call it cryotherapy if you want), Elevation (toes above your nose) and taking your pain medications by the clock are all paramount. There is no need to limit cryotherapy to 15-20 minutes at a time. You can't do any harm by cooling your knee for longer, provided that you make sure to put a cloth or something similar between your skin and the ice pack.

I see that you've already reduced your medications. It's a bit early for that but that's your choice. However, it is not a good idea to take pain relief to dull pain during physiotherapy, as you are doing. That pain you would feel without the medication is a warning sign. By masking that pain, you are preventing your knee from telling you when to say "Enough", so you may unwittingly be pushing too much.

The day that your knee swelled when you did no PT - was that the day you sat with your sick friend? Do you think that sitting around, without elevating or icing your knee, might have had a little something to do with the swelling?

I do know that no two people (and no two knees) heal the same. I've had 2 knee replacements myself and they felt quite different.

Sorry if I come across as a bit bossy. I'm an ex-nurse, and bossiness is an occasional occupational hazard!

Best wishes!

Hi, Celle. Hey, no apologies necessary. I am a trial lawyer and I know bossy when I see it and can deal with it. You did not come across as bossy at all. And my wife is a registered nurse so I have some experience in that area as well! <g>. What we have are differences of opinion in how to deal with individualized knee rehab. I see no gold standard template answer but one that depends on the individual situation, person and results. Since I am getting the results I am I will likely continue as I have and rely upon the opinions of the experts I have retained until their advice proves imprudent. I am very pleased to see others here doing well and would give that same advice. What helps me here is to read about others' success stories as that is a very good experience with optimism. I wish all here the best of luck in their recovery track and hope it works out for them well. Take care of yourself and thanks!

Mike

 

[Celle]

A pretty sensible attitude, Mike!

 

[mgdurand1]

A pretty sensible attitude, Mike!

One of my few! <g>. Thanks, Celle. You take care!

Mike

 

[SFBaySailor]

People in the UK and NZ recover with minimal routine PT - or even none at all. They just do simple exercises, which they follow from a printed sheet they are given. Apart from that, their daily living activities are all they need. And, guess what? Their results are just as good as for people in the USA ( and sometimes even better).

Celle
I see this quoted very often on BS. Can you please refer me to the study that compares the recoveries between UK/NZ patients who have not had formal PT, and USA patients who have had PT? If you don't know, then hopefully someone else does.
I don't doubt that this MAY be true, but I like to see the studies, especially when this is quoted so often as being verbatim.

FYI, my home PT used the "gentle" approach for the first 3 weeks, and then slowly transitioned me to some very light muscle building exercises, like squats. At 6 weeks, I was transferred to outpatient PT. So I do believe that a gentle approach in the first few weeks has worked for me. Outpatient PT was a little harder, but I started slowly and worked my way up.

In my thread, I had complained about muscle pain after PT. This happened shortly after I returned to work at 8 weeks. The increased activity was too much. Most forum members said that since I had reached 130 ROM, that I should quit PT altogether. But I decided not to quit, since I felt that the leg was weak. I found that the pain was reduced by eliminating some of the PT exercises that were too strenuous. It is really a balancing act between activity and rest.

Now I am at 11 weeks and am doing quite a bit of muscle building exercises at PT. The exercises that have caused me problems are still left out of the regimen, but I have increased the load on the other exercises. This has worked well. My TKR leg is now at 65% strength of the non-TKR leg. When I started outpatient PT, it was at 40%, so there has been a tremendous gain in strength, and I can really feel it in my ability to perform day to day activities. And now I can do things better than pre-TKR, like climb stairs and walk long distances.

As you can see from my signature, I am doing quite well at this point. I can walk over a mile now, and the knee doesn't swell. I will be discharged from PT when the TKR leg is at about 80% strength of the non-TKR leg. That is the ultimate goal of the USA PT treatment, to improve the strength in the leg. I had babied my knee for 10 years with bone-on-bone arthritis, and the muscles were very atrophied. I truly believe that one has to put a certain amount of effort into rehab. The knee will not magically heal on its own, and the supporting muscles will not regain full strength with just daily activities like walking..

Roger

 

[Celle]

Sailor,
Josephine our forum "mother hen" would be the person to answer your question. She's an orthopedic nurse of considerable experience with knee replacements.

 

[Josephine]

Can you please refer me to the study that compares the recoveries between UK/NZ patients who have not had formal PT, and USA patients who have had PT?

Actual studies, not I'm afraid. What we go on is the number of MUAs and satisfaction scores which have been published here and there in amongst other studies. That and the personal experience of many British surgeons who have actually spent time in the US, Canada, Australia and elsewhere and could attest to the differences between countries. I've heard them speak at various conferences and spoken with them personally also. As I understand it, places like China and Australia for instance don't tend to go in for this aggressive exercise regime and also have much lower MUA figures than the US and higher satisfaction scores.

But I decided not to quit, since I felt that the leg was weak. I truly believe that one has to put a certain amount of effort into rehab. The knee will not magically heal on its own, and the supporting muscles will not regain full strength with just daily activities like walking..

You're confusing two completely different situations. Recovery and strength building are not the same.

During the early weeks, the muscles are not weak, they are injured and need to be rested and nurtured. In this phase the knee most certainly will magically heal on its own; it's very capable of doing that and really doesn't need any interference from us. In that phase, aggressive exercising is actually counter-productive for all the reasons I have propounded on here ad nauseum!

However, once the healing is done - around 10-12 weeks as a rule - then stamina, strength and general fitness training can be brought in and yes, then some effort and commitment is required to get it built back up again, common sense prevailing, of course!

Another point I would take issue with is about walking not restoring muscle strength. Walking is an excellent means to improve not just strength but general fitness, balance, coordination and mental health. It is widely advised (by the medical fraternity) that if people would just walk for half an hour every day, they would lose weight, increase heart and lung function, lower blood pressure and cholesterol, gain fitness, strength and coordination in a matter of weeks. It truly is the best form of exercise going provided it's not just a saunter but a brisk walk that slightly gets you out of breath. Has to get you out of breath to be effective!

 

[mgdurand1]

Hi, Josephine (I love the "Mother Hen" moniker). While I do understand the value of patient satisfaction scores and the like, if there are no data to support the theories then each side's proponents have only that: opinion. Even controlled studies that do not adequately account for confounders are of limited probative value. I certainly have not done any extensive research on the topic, but as I mentioned to another user here, the concern I have about not doing some aggressive yet not hurtful PT during the early healing phase is the potential formation of scar tissue after the trauma of the surgery and the difficulty in achieving motion if that scar tissue has adhered to surrounding tissue and muscle layers. Obviously there are a large number of proponents of PT right after the procedure and it is not what I would call a "revolutionary" school of thought (mine gave me exercises to do at home for a week and then started me on outpatient PT after a week). Maybe the difficulty I am having here is a definitional one: what is "aggressive" or "intensive"? To me that is working diligently without being overly painful or causing more damage. I am 3 weeks post surgery and the exercises are much easier to accomplish and walking is enjoyable again. In the end, as is true with most things in life I guess, what we need is moderation and common sense. No single process will work for everyone.

I do thank the providers of this site for the opportunity to see what others' experiences are and to read and attain some encouragement online. This is a difficult surgery and recovery no matter how you cut it poor choice of words, I know), even in the best of cases, and it is nice to have this group to interact with.

Mike

 

[50yrold]

This is a GREAT conversation, and exactly what I hoped to see and participate in both preop and postop. Its meaningful, and supportive. Thanks for ALL the great contributions toward it on this thread.

I will offer my additional personal insights here. First, to disclaim. I fervently adhere to the principle that all will heal at their own rate. But, I also believe that each can effect better healing by both listening to, and challenging their bodies in the right way. My frustration with a perceived plateau, and with the fact that the regimen has been nearly identical for five surgeries over the last 26 yrs was addressed correctly by my PT on Friday. I told him that I wanted exercises tht would focus on my weaknesses, and thats what I got, and they are already helping. I am less than 3 wks postop, and havent used a walking aid in ovr a week. My OS reported to my wife postop that he had to take an extra half hour to deal with legs that were much more muscular than he normally sees. Knowing I had and have good muscle tone, I believe I am up against a clock of sorts to stop any additional atrophy that could be avoided. As such, I aske my surgeon if there was anything I could do to damage the joint or tissue repairs/sutures, etc. by working the leg hard, and I trust him when he said no. I also know the cycle of working the leg hard and its repair cycle, and have respected what has become a three day cycle of the same.

I also firmly believe in visualization. If I can see it, I can understand it, and better effect the change I want. I am a guy who has to have the big picture and small picture in mind to excel. That said, I researched on youtube and google all the tkr ops I could find both preop ans postop. I must say that mgdurand1's pics are of the most help...thanks for posting. It was much like what I had envisioned, and very affirming.

In this, my third postop recovery week, i have also gone back to work half time, seen clients, and volunteered 8 hours in twomdifferent shifts. Its been great for my morale to get out and see people, drive, and feel the accomplishment and gain of testing myself and my new knee.

Thanks again for all the great contributions. They all help!

 

[Roy Gardiner]

But, for some reason, i a, getting exasperated after only 2 wks ofmrehab with the constant cycle of renewed pain and inflammation after PT. maybe its because I am older now, or because i set my postop rehab expectations too high. But to be told by my professionals, who have doctorates in PT, and specialize in knees, to do my ever expanding PT twice a day, and wearing myself out doing so, is in direct conflict with what I am reading here

I would be very interested to see these folks' reasoning, seriously, since we on BoneSmart think this approach is wrong. Any chance you could post it here?

 

[mgdurand1]

50yrold, Congrats on your progress, my friend. The comment to listen to your body during the healing process is to me excellent advice. After week one I started doing that and the progress has been much better than anticipated. My personal situation is different than yours in that my knee was bone on bone for years and to say the leg was not muscular would be an understatement. But we have a plan in place and it appears to be working so I will continue to follow it.

Wish I could take credit for the pics but someone else posted them in the thread. They were something else, as they say!

Take care and continue on your road to recovery. Anxious to hear your progress.

Mike

 

[Celle]

Hi again, Mike,
There is an article in the Library about the difference between normal scar tissue and adhesions (those are the ones that cause trouble) and what pre-disposes to them. I know I've read it, but i can't find it! I did try using the Index.

Josephine please can you help us out again? Thank you.

Caryl

 

[1woofer]

See this study on standard outpatient physical therapy versus no outpatient physical therapy regarding range of motion after a primary knee replacement:

https://www.slideshare.net/fuadhazi...f-knee-motion-after-primary-knee-arthroplasty

While the study does not address aggressive versus nonaggressive outpatient physical therapy (or explain how aggressive the "standard" physical therapy in the study was), the study seems not entirely irrelevant to the aggressive/nonaggressive debate.

 

[mgdurand1]

Excellent article/study. Thanks! I agree it does not address the agressive versus non-agressive issue, but I also agree it is relevent. Funny thing in my case is that the most intensive aggressive PT I did was the first week when I was following the sheet and wanted to work as hard as possible When I started out-patient PT the following week the therapist slowed me down and my progress seemed to improve Thanks, and appreciate the study. Interesting reading!

 

[Celle]

As I understand it, aggressive physiotherapy is pushing exercise beyond discomfort to the point of actual pain, or requiring the patient to perform hours of exercise every day, often to the point of exhaustion or despair. It is also intimidating the patient with threats of never gaining a good ROM, unless this demanding regime is followed. It's inappropriate, especially in the early post-operative days.

We read a lot about those situations here on Bonesmart. Recently, there was even a PT who, without warning, forcefully bent a patient's knee backwards until the heel touched the buttocks, causing excruciating pain - it was a manipulation without anaesthetic, dangerous, and a physical assault.

I wish I could find that article I spoke about, because it explained the possible causes of adhesions and suggested that too much PT in the early days further aggravates soft tissues that are already wounded, irritating them still more and increasing the likelihood of developing adhesions.

Everyone needs to do some exercise after a knee replacement - I'm certainly not advocating lying there like a log and not moving! What is debatable is the amount of exercise needed. I think you need to find a balance between keeping the soft tissues moving and doing so much that they become irritated. I guess that balance differs with different people.

I think that there are two different stages of recovery from TKR - firstly, the early stage, when you just need to keep things moving and try (gently) to increase ROM; secondly, the stage where healing is complete and you do strengthening/ conditioning exercises.

 

[SFBaySailor]

Celle
No PT hate here.
I have nothing but good things to say about my in-home and out-patient PTs. They are licensed medical professionals, and I have respect for their knowledge and abilities, as much so as I do for my OS. I have benefited greatly from the therapy.

The study is interesting. But it only talks about ROM. ROM is not the only measure of recovery. Other benefits of PT are improvements in balance, coordination, walking (I was walking improperly until my PT showed me), muscle strength, etc, etc. I needed work on all of these.

Roger