TKR When to transition from walker to cane?

[skigirl]

Harplayer, I know that you have read my posts on Sandy's thread---they all should be directed at you too. I have never heard of such foolishness---"I had to negotiate with my therapist"!! That sounds crazy to me. You are the employer----he is the employee. He is not a professional and is doing his job badly, yet you continue to employ him? There must be part of you that thinks that all of us are wrong and that the idiot is right?

I agree with Jo---I would not allow this person into my house. I personally think home pts are not trained as well as the ones that work in the clinics. Here is my story---I stayed int he hospital for two days, left with a rom of 90. Then, I stayed in bed 90% of the time with my leg propped up on three pillows. at two weeks I began to see my regular pt at his gym, I NEVER experienced one minute of pain. He massaged my knee and I did some leg lifts and heel slides with him. Then he gently massaged my knee. I never did any other exercises at home---I iced and elevated the knee.

I used crutches for two weeks--no walker ever. At the end of two weeks, spent mostly with my knee elevated, I did not have a lot of swelling in my knee. I drove myself to the pt--and also never used a cane. My pt continued to do 5 min on the bike and then, leg lifts, clam shells and massage. I did not begin to do strength training until about week 4 . At four weeks I rode my bike with my bike group for 20 miles--and I basically never did a singel exercise at home when by myself.

So, all of the stuff you are doing is for nothing---you are just making the swelling worse and worse. You cannot bend a garden hose full of water---you cannot bend a very swollen knee. You are allowing this stupid man to set back your progress---- to make your swelling worse. Please read the articles that Jo gave you---and discuss this with your OS--mine would have hit the roof if I told him the pt was causing my knee to swell more.

 

[Dulcimer Diva]

Skigirl, your therapist is one of those rare ones in the US who follows the Bonesmart mantra and doesn't mind your preference for the UK model of post-op TKR recovery. The reality in most of the US is very, very different. Most American OSes who do TKRs are firm believers in physical therapy as soon as the patient is mobile enough to go to the bathroom instead of using a bedpan. Having a prominent American surgeon (unless he is one of the rare ones) practically guarantees that if you insist on the UK protocol (and strict Bonesmart philosophy) you will be like the little apocryphal Dutch boy sticking his finger in the dike hoping to hold back the sea. I mentioned the UK model in PT the other day and everyone thought I was nuts. The best I can do here in rehab is to firmly tell my therapist not to go past my "STOP!" point--and to do only as many reps of a particular exercise as I can comfortably (or not painfully) do. She still believes I can do more but backs off when I tell her to. Just about every other PT I've ever encountered strictly adheres to the American model. It may take an influx of UK and former British-Empire trained surgeons or a wholesale revolt by patients to change things. I know that if I refuse to do formal PT I would probably be dropped as a patient by my OS, or at least chastised until I have made enough progress in recovery. I will say two things in this rehab center's PT dept.'s favor: they let you switch therapists (as I did when the first one pushed too hard and responded to my fears of swelling & stiffness with "Of course it will swell. Then it will go down. Then it will swell again--you will have good days & bad days. You must not be afraid of pain."); second, I've been here 10 days and nobody's whipped out a goniometer yet. (They did in hospital upon my discharge).

 

[skigirl]

Sandy, somehow I doubt that you have any trouble at all telling the therapist when to stop!! Harplayer does not seem to be comfortable being assertive. So, yes, if I did have someone whose idea for me was to keep exercising and make my knee more painful---I also would have no trouble at all with saying stop---and they would stop, no problem. I think the therapist is taking advantage of her---pushing her into the pain level.

It is obvious from the studies that the folks from the UK have basically the same outcomes as do the patients in the US---they just don't have the aggravation and the pain along the way. I have to admit that I stayed in pt for a long time. If I had to do it again (oMG, what a thought!!!!) I would go even slower at the beginning. Then, at about four weeks, I would begin to strengthen the quads. I am basically back to my former level of fitness now and, just for laughs my pt measured my legs last week when I was there----right--154 and left 149. I designed a shirt for them for a charity run and signed up myself for the walking part of it. My first foot race!! Kelly

 

[bottomshollow]

Not US PT for knee and hip replacement patients is aggressive. None of my or my hubby's in-home PTs were aggressive and the out patient PT facility where my hubby is having his therapy is not aggressive. All the PTs we've been involved with over the past 3 years have been very concerned about not causing pain. Of course, I live in eastern North Carolina---so maybe it's just the slow Southern style of small city life that dictates the therapy approach here.

 

[Celle]

There's nothing wrong with the US approach to PT after a TKR - except when the therapist pushes it too far and causes pain and further swelling. And, except when the patient pushes it too far with too much exercise at home as well as going to PT.

It's the American way, to try and rush things. That doesn't mean it is any better or any worse than the UK approach, of minimal PT. You can't rush healing of a knee after TKR. It will take as long as it takes, no matter which approach is used.

As Skigirl (and Josephine) have said, the long-term results are the same, no matter which approach is used.

Where I have a problem is the number of people who post on Bonesmart saying that their PT hurts them, tells them to "push past the pain" and lays a guilt trip on them if they protest. Often, this results in further swelling of the knee, which retards progress. That sort of approach does no-one any good.

I can understand that some people have difficulty in being assertive, especially if their PT's approach is condoned or encouraged by their OS and their families have also bought into the "no pain, no gain" philosophy. No doubt, both PT and OS may try to "guilt" their patient into complying.

I don't believe, however, that any OS will drop their patient for having a different philosophy towards post-op rehab. Being cynical, my mind says that they would not want to pass up the fees!

I still maintain that it is up to the patient to call "Stop" on any procedure that causes excessive pain and swelling. It is their body. I can't imagine any other circumstances where someone would allow an almost-stranger to bully them into accepting being hurt time after time and being made to feel it is their own fault.

 

[harplayer]

Well,
It is 1:40 am and I am still awake. Some nights it is the inability to get comfortable...some nights (like tonight) it is the inability to turn my mind off. I have been reading and re-reading the most recent posts from all of you...I do have difficulty confronting my PT...although I am vocal about expressing my pain during our sessions. Both my PT and my family members are staunchly planted in the "no pain-no gain" camp...which makes me feel like a lone voice. My situation, as described to me by my OS, is that I will most likely have a much improved yet very conservative outcome from my TKR. My knee was severely damaged in an accident at age 14. The knee was stabilized without surgery...which seemed to work for about 5 years...until a ballet class in college...when my knee totally blew apart and was surgically repaired...1974. Fast forward 40 years...and here I am. My OS indicates that my FINAL ROM at the end of Tx will be 90 degrees...under anesthesia at the time of surgery he was only able to get my new knee to 110. I am happy for others who have been blessed with 90 degrees when they are less then a week post op...or 90 degrees at transition home. I have been working to do what my PT has designed for my rehab...and after 3 weeks I am only at 50. All this pain and hard work...and such limited returns. I am overwhelmed...terrified...the last exchange was to let me know that my ROM has not changed in a week...and if I don't get busy...this will be all I will be left with.

I can't sit in a chair with my knee bent with my foot flat on the floor without significant pain....I continue to elevate, ice, stretch and take my meds...frequent walks around the house (hourly)...sigh..nights are so long and overwhelming....

Harplayer

 

[Celle]

Harplayer, you deserve a hug! ((((((((((Harplayer))))))))))

We do understand how hard it is sometimes!

No matter how much he wants to help you and no matter what your OS and your family say, you must not let the PT to do anything that takes you beyond discomfort. Sure, you express yourself vocally when he hurts you, but you must tell him not to do that again (or you will kick him with your good leg? - just joking!)

While your knee does need some help to bend, pushing it until it causes you real pain is just not going to improve things. Tell him to only do it until you say to stop. As the swelling goes down, you will get a little more bend.

So, it may only get to 90 degrees, but that will be an improvement on what you had before and 90 degrees is quite workable. But, "all this pain and hard work" is not going to make it happen any sooner. You've had a huge operation and all the soft tissues need time to recover and heal.

Please don't think we're lecturing you - but we've been there and we just know that causing pain is counter-productive.

 

[puffin]

harplayer
You are in a very tough situation - I also had my TKR because of a major accident that never recovered - but the important thing is not to create too much pain and swelling which will delay your progress

You say that you are vocal about your pain during PT - but do you actually make it clear that you want them to stop? I think you need to have a chat with the PT before a session to make it clear that you want them to stop when you say stop - and that if they are unable to do this then you will need to find a new PT

Many have said this before on your thread - but a very swollen knee will not bend as much as one with less swelling - so pushing ahead with great pain is just delaying your progress. You need to make keeping the pain and swelling under control a priority. Bend until discomfort but no further (perhaps try it on your own to get a sense of the different feelings). But you need to be clear with the PT about when you want them to stop.

It doesn't matter what the PT and your family think about no pain no gain - it is your knee and it is you that has to live with the consequences

Take care

 

[kneeper]

Please try to remember that you are so early in the process it is difficult to tell where you'll end up. Celle is right. As I think Roy is fond of saying, your knee is not unfit, it's injured. I also agree with Puffin that it is a good idea to talk to the PT before the session starts.

I am one who probably got to about 115 at my last PT measurement--a slight improvement of ROM from before surgery but my rom was bad pre-op. But I can tell you that from year 1 to year 2, it has certainly *felt* like I've gained a few degrees--and in any case feels more mobile and so much better than before the surgery.

 

[skigirl]

There are many people on this board who end up with a rom of 90---and it seems to work for them. If you have had a bad knee for 14 years, than 90 with no pain will feel like heaven to you. If you look at Campervan Margaret and maryo52, Mary you will see folks who had a less than ideal situation, but managed through time and lack of aggressive pt to persevere to an andequate outcome.

I know this is hard for you---but your family and your pt will not have to live with this knee---YOU will. YOU will also have to live with the pain and swelling that results from too much aggressive during pt. Ultimately, all decisions are yours---and I will accept your decision not to talk to your pt, if that is what you want. However, you are an adult and have the right both legal and ethical to determine the course of your own rehab. Here is my approach to unpleasant tasks---think, 5 minutes of being uncomfortable and the rest of my life is happy!!!

 

[Dulcimer Diva]

Several observations:
1. Measuring flexion in the supine position will give a lower reading than in the seated position with foot on a sliding object on the floor. Therapist confirmed this yesterday.
2. Since Harplayer's in MI and I'm in IL, perhaps the "American" TKR recovery protocol is firmly embedded in a Midwest ethos (keeping farmers' hours, strict work ethic, ennobling suffering even when it's needless, discouraging complaint). It is lightheartedly spoofed by Garrison Keillor in describing the folks of Lake Wobegon, but the reality is tough to endure.
3. In the US for those of us too young for Medicare and not rich enough for unlimited private pay, the "American" approach is likely heavily influenced by private insurance bean-counters. The discharge-to-home-from-rehab criteria for most OSes around here are 90 deg. flexion, -7 extension, and independent dressing, bathing and toiling. Ideally, one would stay in rehab until they can reach these criteria comfortably. But insurers allow 10-14 days for a TKR inpatient rehab (10 single, 14 bilateral) and both the patient and therapist must advocate tirelessly for a reasonable extension. No doubt that many therapists are constrained by needing to discharge a patient within the time period that the insurer finally agrees to cover (or whether the patient is willing and able to pay out-of-pocket for the extra days). One more reason why I (and most doctors) HATE the third-party-payor system. More than that I will not say lest I get too political for the rules of this forum.

 

[harplayer]

Hi to Al,

Just a quick update...with the wise counsel of my Bonesmart friends and so much good encouragement I DID speak with my PT today before my session! The result is very positive! I had a much more productive and much less painful PT session! We totally ignored all ROM activities at my request...and focused on walking, stretching and GENTLE message around my new joint! I also shared a few of the Bonesmart articles related to swelling, ROM and the Mantra. VICTORY!!! And...no serious, all day achy pain after my session!

Thank you everyone!

 

[skigirl]

Thank you for listening and learning. Each time that you take charge of your own life, it is a good life lesson for you.

 

[Celle]

Hooray! Well done! Now your PT can help you, instead of hurting you.

 

[Jamie]

That's GREAT news!!!! Sounds like you have a good therapist after all. Stay on that gentle path and you will begin to see results as the swelling lessens. I noticed you were having trouble sleep9ing at night.....you are taking your pain meds through the night, right??? Doing so will help you get needed rest.

Try to ignore the comment about "you'll be left with this ROM." We have BoneSmarties who gain ROM for a year or more. Some folks are just slower to recover than others. And, given your history of injury with your knee, it does sound like you may need quite a bit of patience with this.

But I can't wait to hear how you're doing at about 6 months. I bet it will be quite different from today. Relax, go slow, celebrate even the smallest of progress with us and you'll get there!!! ((((HUGS)))))

 

[Titianlady]

BRAVO!!!! Well done!!! Now you don't have to dread therapy and won't be in pain for a day after you session!! Good for you!!

 

[puffin]

Well done for speaking up to the PT - I'm sure that your ROM will also improve as a result of the reduced pain and swelling

 

[bottomshollow]

harplayer, I am so proud of you for speaking up!!! I know how hard that can be---I used to be very reluctant to rock the boat even a little bit. Now there should be a lot of improvement in your recovery---and that is a very big deal for you. I'm looking forward to future updates from you.

Take care and keep us posted. We care.

 

[Tennis Nut]

Harplayer, sounds like you still have lots of swelling and I think your PT was attempting to do lymphatic drainage on you but was too aggressive. Lots of massage therapists and pts are trained in lymphatic drainage. You can also do it yourself. Elevate your leg and starting at the hip, Gently start brushing your hands back toward your hip. Sort of like pulling a rope hand over hand. Work your way lower and lower toward the knee. You can gently do sides of knee, just not the incision itself. It will feel good and you can do this several times a day. Try it and hope it helps. Google it for more info. Good luck.

 

[harplayer]

I have now graduated from home-based nursing and PT to outpatient PT starting on Monday. My milestones this week include achieving 70 degrees ROM at my home based exit eval (started at 30)...climbing the stairs 1-2 times daily for showers and sleep (we live in 125 year old Victorian farm house with LOTS of stairs)...continuing to walk with a cane...and being able to sit in a chair at the kitchen table to eat a meal. I am still elevating and icing as swelling continues. Because of the severity of my knee injury 40 years ago, my final ROM is only predicted to get to 90...so making it to 70 degrees means I am getting closer I wish I could have the kind of ROM I hear about here on the forum...most members seem to reach 90 early in their recovery...and I'm only gonna get to 90 as my final result..sigh. Well...it will still be better than the 50 ROM I had before my surgery!

I have a question...do others on this list struggle to sleep in a bed at night? Since returning home, I have been most comfortable sleeping in a more upright position with my leg elevated. I went upstairs last night to try our bed for the first time in over 3 weeks..it felt so good to lay down...until it didn't I was ok for about 20 minutes...and then my leg and areas around my knee began to ache...I stayed on my back for several hours, trying different supports of my leg/knee with pillows...but could never sleep more than about 20 minutes! I hung in there until about 5:30 am...then begged my hubby to help me transition back down stairs to the recliner. Sure wish I could get some sleep! I am typically a side sleeper...so attempted to lay on my side with a pillow between my knees...OUCH!

Thanks for any suggestions...I remain,
Tired but Hopeful Harplayer