Karen Truitt, Physical Therapist

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My name is Karen Truitt. I am a physical therapist. I went to undergraduate school at USC. I have a degree in psychology and a Masters Degree also from USC in physical therapy and have practiced in hospitals, outpatient, but have done home health for many, many years at this point.

I have seen patients with hip and knee replacements for more than 30 years, uh, at home. And have had a chance to see how that works when they come home from the hospital, be a part of that transition to home, be a part of the adjustment to being at home, and helping them with that initial rehab process. So, home health is a unique opportunity to spend time with people in their own environment where they have an opportunity to really hear what you have to say. To be able to deal with their environment in the sense that whether you have stairs or-or areas that are dangerous.

Rehab after a joint replacement, a hip or a knee replacement, is a process. And there are many steps in that process. There's the-the preoperative process where people will be meeting with their surgeon and planning the surgery. They have the surgery. They have their hospital stay. And then if they are seeing me, I'm the next step in that process. Where I see them at home, am able to work with them to help get them adjusted to being in their home environment where it's safe, help monitor the incision, help improvement their function and mobility, manage their pain and, uh, swelling. Once people are at the point that they are able to go to outpatient, then that's what they do, if that's what their surgeon prefers. So we provide the education for these people to continue their exercises at home and provide the-help provide a smooth transition for when they go to outpatient.

One of the things that we look at when we first see people after they had joint replacements is get a sense of who that person really is, what their goals are and how they see themselves three months, six months or a year down the line. Generally speaking people are wanting to be more mobile. That's why they get into doing these surgeries. But everyone is different. My job is to help them achieve their goals. For them to really reach their ultimate goals, whatever tho-those goals may be, require their involvement, and their significant day-to-day participation in the process. Some people are going to require a little bit more encouragement to achieve what it is they want to achieve. And then there are those who are over-achievers, who, um, immediately after these joint replacement surgeries, we may need to slow down. They need to listen to the therapist they are seeing to help guide them down a path that's going to make sure people either don't under achieve, or try to over achieve, where you can actually do yourself a little bit more harm in the process.

This is not a fun process for anybody, and I always say we have to find things to laugh about, because otherwise we can all just sit around and cry, because this is such a process.

As a home physical therapist, I go to the person's home within the first day or two following their discharge from the hospital after their joint replacement surgery.

The first visit, whether you're seeing someone in home health as a physical therapist or whether it's as an outpatient, is an evaluation to determine what the limitations are that that patient has [and?] have an opportunity to see what their functional abilities are when they come home, because people are coming home generally now after just a few days in the hospital, which is very different than many years ago, when people would be in the hospital for sometimes upwards of a week. In many cases, go to rehab. And then after that, we would see them at home for as long as a month. That's no longer the case. So we're seeing people at home who are still very acute. They're literally just a few days after major surgery on their hip or their knee.

We deal very much with the whole person when we're seeing people at home. One of the things that I think is a shock to people after joint replacement surgery, is they go into these surgeries knowing intellectually that they may have to deal with someone like me when they get home. But what they don't realize is- and frequently is a huge surprise to them- is that it's a huge knock to their endurance. It's painful. It's fatiguing. It's frustrating. It's sometimes boring to do what we're asking you to do. And it takes longer than people think, because they go into these surgeries knowing that they have a bad joint. That it's very seriously impacted their quality of life. But other than that, they're not ill. And you tend to think that you go home and pick up where you left off and that's not the case.

I think that people would generally say that the rehab following a hip replacement is easier on a relative basis than a knee replacement. A knee replacement, we're looking at getting movement, or what we call "range of motion" back in the joint at a fairly-fairly quick pace if we can because we don't want scar tissue to form in there, which means that it limits their ability to move the joint. That's not so much a concern with a hip replacement.

The overall goal with both is to get people to the point that they are no longer homebound. So their endurance has improved. If the surgeon wants, this-they will be sent to outpatient ultimately. With a hip replacement patient, it depends en-to some extent how active they were before the surgery. The more active people are with all of these procedures, the more active they are before the surgery, it means that they're going to progress more quickly after the surgery.

We don't do anything that at this early post-op stage, that involves a lot of resistance. We're looking at getting mobility back. In the case of a knee replacement, we're looking at getting the range of motion in there.

One of the things that everyone who has a joint replacement needs to recognize is the importance of their role in the process. That their buy-in to doing what the therapist is asking them to do and following up with the exercises and the programs that they need to do at home, as well as an outpatient, is critically important to their success.

There are many things that we look at, at a-as a part of the process of looking at the whole person at home. So I don't walk into someone's home and only look at that knee, or only look at that hip. We do incision monitoring and help instruct the patients in dressing changes. We look at the incisions because infection risk after a joint replacement is something that is significant, something to be avoided.

We're looking at redness around the incision, any drainage that seems unusual. These incisions generally dry fairly quickly, increased pain, increased fever. Although a low-grade fever initially, postoperatively, is not generally of concern by the surgeons.

We teach, uh, edema management, or swelling management. That helps with pain management along the way. We deal with positioning, how they deal with movement, how long they should sit, how that affects swelling they may have and what they need to do to help-help monitor that.

There are several reasons that it's very important to co-control the swelling. One of the main ones, is it really helps with pain management. Uh, it helps with-with healing of the incision. We also are wanting to make sure that we're managing the swelling to prevent risk of blood clots.

Ice is a critical piece of the puzzle in pain management, along with pain medication and elevation. Some surgeons will recommend ice machines. But low-tech works very well. Uh, whether it's gel packs, whether it's ice that people use in bags as long as it's large enough to cover surface area. Do not ever use heat immediately after these surgeries, because the heat will increase the swelling in the area.

Pain management after a joint replacement is very different than pain management after other types of surgery that-that people might have. And staying ahead of the pain immediately postoperatively is critically important, because it has an immediate and significant effect on how quickly people progress. So if you have another form of surgery, you go home, you're given pain medication to take. You take it as you need, you relax, you wait for time to pass and you wait for it to get better and you cut back on it. Cutting back on the pain medication too soon after joint replacement surgery actually can lengthen your recovery period. So staying ahead of the pain and making sure that the pain doesn't get ahead of you, which is an avoidable problem, it takes far longer to get the pain back under control, and it is a completely avoidable problem.

To get that movement in there, both bending and straightening, or we call flexion and extension, if they are in pain up to an eight out of ten, I'm okay with that, because it's very time-limited. We're not leaving it that level for very long. But if they have a good blood level of their pain medication in their system at the time, then they're going to be able to tolerate more. And as I jokingly say to people making fun of myself, if they can tolerate more, they're going to progress more quickly, get rid of me sooner, and move on with life as they prefer it.

With hip replacement surgery, we're looking at a combination of exercises and progressive ambulation. Or increasing the distance and-or time that patients are able to walk. Generally speaking, when people go into having a joint replacement surgery, because of the pain they're in, because of their degenerated joint, they get into a position where they have one version or another of what I call "the funky walk". They are not walking normally any longer, because the pain has made it so difficult to stand on that leg that they don't want to stand on it any longer than they need to, and they don't want to move it any longer than they have to, and move it any more than they have to. Doing some of the exercises along with the walking, they complement one another, because we're strengthening some muscle groups that help improve the way you walk so that you no longer have these gait abnormalities that were present before the surgery.

It's not unusual for people to complain of pain in other joints. Uh, they compensate, which means they may use their back to help advance their limb, as opposed to bending their hip and knee enough to walk in a straight manner. And sometimes because they're-been walking in a-in an abnormal way for so long, it's not unusual for people who have hip surgery to complain of pain in their knee. Or patients who have knee replacement surgery to complain of pain in their hip.

I, for many years, have retold a story to people I see with knee replacement. And it's a story that is something that a man I was seeing several decades ago said to me that I thought was so funny. We were working on his knee replacement rehab. And we finished one day, and I looked at him with a twinkle in my eye and said, "We're finished. I bet that's the best thing you hear me say." And he looked right back at me with the same twinkle in his eye, and he said, "No, Karen. The best thing I hear you say is, 'Goodbye'." [LAUGH]

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