When a patient wakes up after surgery and it still in the hospital, he or she should expect it to be uncomfortable though physicians do a great job managing post-surgical pain. Getting up within the first 24 or 48 hours is crucial but not a “walk in the park.” Going home is where the real recovery can begin. Though in-home physical therapists can visit you, Schaffer prefers outpatient physical therapy—when appropriate—since it forces a patient out of the house, which can positively affect a patient’s mentally. Every patient is different when it comes to pain and mobility but Schaffer’s biggest concern is to make sure his patient can do what he or she hoped to be able to do post-op. When it come to hips the key is to just walk, walk some more and just keeping more every day. Knees are much more difficult and can take up to three months of physical rehab to realize the goals that patients strive for.
BARRY: When we talk about a total knee and physical therapy. I think it's important to be prepared post-operatively to get out of bed 24 to 48 hours post-operatively, and understand that that's not going to be a comfortable moment. Understand that when you're in the hospital, you're going to be bandaged, your leg is going to feel thick and bloated, your foot might even swell, in the hospital we're going to do as much as we can to negate some of that, but we can't negate all of it. You'll be on a regimen of medicines to help control pain and all the other things, but we're going to our advantage so we still get you out of bed and be mobile. That's going to be your best medicine, to get you out of the hospital and get you home.
BARRY: Once we get you home, you're either going to have in-home physical therapy; so, a therapist will come to the house one, two, three days a week. Walk around the house with you, get you acclimated to your surroundings, make sure there's no physical barriers to you being in the home. If you have crutch training or walker training, we'll be doing that in the home. We'll start the basic exercises in the home, and it's more about motion and strength than anything. The knee is a pretty simple joint; it's a hinge joint. It goes up, it comes down. It's not like the shoulder or the hip where it moves in a 360-degree fashion. We just need to bend it, and we need to extend it. We need to get all your extension, and we'd like to get 90 or more degrees of flexion.
BARRY: Sometimes, if a patient's healthy enough and strong enough, I'm a big proponent of going directly to outpatient therapy. Some surgeons aren't, some surgeons are. It just depends on the surgeon. My bias towards going directly to outpatient therapy is it forces you to get out of the house. It then becomes an event, you know, if I come to the house and you're doing home health with me, I'm there for 30 to 45 minutes and I'm gone. But if you've got to get in a car, come to my office, come up for therapy, go back to the car, we just took that process and made it probably close to two hours. So you've got to be more active to engage in outpatient therapy. I think that has some very positive ramifications. One, it f-gives you the impression you're not home-bound. The surgery was a success. I can still move and be out in public and do my thing. Two, it forces you to be more active than you otherwise would be. Because as soon as that home health person leaves the house, I guarantee you they're sitting back on the couch and they're kicking back.
BARRY: As they move into outpatient therapy, that's when some of the harder work starts. That's when we really start talking about really getting full motion and pushing them to the nth [PH] limit. Getting full extension's important. And I don't think people really understand why. When you take a step, if your knee isn't fully extended, you're going to walk with a bent knee the rest of your life. So, we want your knee to be able to get to that terminal extension, if you will, that allows you to in all senses of the word, normalize your gait or your walking pattern. The other thing we want is we'd like to have 90 degrees, but I'm a proponent of trying to get to the 110 to 120. I think that just gives the patient a little bit more degrees of freedom to move and to be comfortable to the things they want to do.
BARRY: But, the point of the surgery is what is the patient want to do? Why did they have it done? Did they have it done because they couldn't get on the ground and play with their grandkids? Did they have it done because they couldn't walk upstairs? Did they have it done because they couldn't walk around the block without pain and they want to walk for exercise? That's the reason to do the total joint. That's where we look at what's your functional ability to get back. You see me for a total hip, day one I'm going to see you for an hour. You and I are going to create rapport, we're going to trust, we're going to create respect from one another, and we're going to be on a first name basis.
BARRY: So, we do work on strength. We do work on balance. Which is extremely important, and probably the one thing in therapy we spend more time than anything on with our total knee, total hip population, is balance.
BARRY: The-one of the killers in our society, as we've been able to live longer, we get more falls. I can't tell you who's going to be with me for a week, and who's going to be with me for three months or four months, until I meet them. Until I know what I'm working with. We make therapy go as fast as possible now. We want people to get better faster, we want them to be back doing all the things they want to do. Everyone has different motivation levels. Everyone has different pain levels. Everybody has different physical levels, and everybody has a different body type. I will tell you my more physically fit, more motivated patients absolutely do better than everybody else. Hands down.
BARRY: If my 85 year old lady, all she wants to do is walk around the house with her can again, because that was her previous level of function, that's what we're working towards. We're going to get off the walker, we're going to teach you to walk 35 feet, because that's all you need to do, and here's your cane versus my tennis player, who needed his total knee done. He might be with me a little bit longer because I got to get his knee right. I got to get his motion back, his strength back, his balance back, and then we got to work on a little bit of that lateral motion stuff. We got to work a little bit on that kind of dynamic activity that he's going to have to accomplish to play tennis again.
BARRY: But when we talk about rehabbing [PH] a total knee, most if not all, are on a walker. They still have pain when they put their food down. They still don't have all their motion and they're definitely weak, um, and lacking a lot of strength. They may even still have the staples in their incision across their knee.
BARRY: Typically, when you come in, your first visit, I'm going to assess exactly where you're at. I want to know what you're able to do, what you're not able to do. Can you get up and down from the commode by yourself? Can you get in and out of bed by yourself? I'm going to assess what the motion of your knee. Is it totally straight? How bent can we get it? Is that relative to pain, or is that relative to joint stiffness or muscle tightening? What are the ramifications regarding that, and stopping that motion? I'm going to assess your strength to see how strong you are. And then I'm going to look at the rest of you as well. I'm going to see how strong your hips. I'm going to see how strong your arms are; how strong you are everywhere else, because a lot of times we get caught up in the knee, the knee, the knee, but we've got to pay attention to the rest of the body. It's along for the ride too. It's a one big kinetic chain; I can't disassociate your hips from your knee. It doesn't work that way. Some people are much more debilitated than others. Some people are much more so... There's so many factors that play in to being able to determine what your rehab's going to look like because everybody's individual. And that's what-that's what I love about therapy, is its ever changing. I never have two patients that are the same. I think one of the problems sometimes with therapy is patients will talk to their friends, they'll talk to people who have had a total hip, that have had a total knee, and they'll say "Oh, my therapy went like this, this, and this," and they've set up expectations. While that's great, and you should talk to people who have had total hips and total knees, but you should also understand that total knee is different because it's going in you, and you are different than your friend.
BARRY: What we really focus on early on, is the faster we can get your motion, the faster we can make your rehab go. You can't strengthen something that doesn't move. If your knee doesn't move, I can't make it stronger. But if your knee moves, I can move muscles, and muscles and activate them. And they can get stronger. And then we work on a lot of standing, moving type activities. I can put you on a table and have you extend your knee and slide your heel to your butt all you want, and those are great things for the house, and we do them and they're necessary. But it's not functional. Nobody walks around on their butt, so you really want to get the patient up and get them working in a functional position. You know, patients have this expectation of "Well, that's going to hurt." Yeah, it's going to hurt, but it's functional for you. When we need your knee to remember how to move. We need your knee to remember it's okay to accept weight. The pain you're feeling now is not arthritic pain; the doctor took that away from you. What you're feeling now is post-surgical pain.
BARRY: You know the old adage "No pain, no gain?" I'm not a big fan of that comment anymore, but in total joins we're willing to accept a little bit of that. To push the patient a little bit further, which comes to the point of should they premedicate before therapy? I [think?] that in the beginning, absolutely. Is it for everybody? No, but it certainly has its place to take the edge of what they're about to experience. A lot of physicians now will tell their patients to premedicate before they come see us, and then what we like to do as we get into the later stages is make sure we're weaning off of that. We want to make sure we're not masking too much and that that they understand that this is tolerable.
BARRY: Um, the other thing we talk about with patients is when you're done with me, now what? What activities are you going to do to maintain the health of not only yourself, but of the-the total joint we gave you? If they say "No, I'm not much of a gym person," we’re able to print them up a program and say okay, these are some exercises I want you to do at home. And it might be simple things like squatting and free squats. Standing on one leg to maintain balance and work on their balance. Simple things like walking up and down stairs, or just putting one foot on a stair and just doing step raises. Um, if the patient's going to go to a gym, that great. Love that. As a therapist, we'll talk to them about which machines they should use, which machines they shouldn't use, how to appropriately use those machines. You know, some therapists will make house calls to the gym with them to go through the machines. I think those are all important points because there's some things you want to do, some things you absolutely don't want to do. We want to look at weight-bearing and loading activities. So, I'm not a big proponent of a whole lot of things where in physical therapy speak we talk about open kinetic chain, where your foot is no longer on the ground. You know, most people will think of a leg extension, where you sit down and you put a bar at the end of your shins and you kick your feet up. That's going to give you good strength of your quadriceps muscles, which helps the knee straighten. So, I will recommend that. Is it my favorite machine? No. I'm more in to a machine that's going to allow your feet to be on the ground in more of a functional position; be it a modified squat against a wall, like a wall sit. Be it a leg press machine that one can tolerate. And those machines need to be set at angles that the patient can tolerate. So, the patient needs to know this is as far as my hip goes back. Post total hip, they may have a little bit less motion getting their knee to their chest, if you're on a leg press you need to be aware of that and be able to set the machine appropriately. Hitting the appropriate weight, and using the appropriate weight.
BARRY: Through therapy, one of the things you should be learning is what's muscular and what's joint. What's a good hurt versus what is a bad hurt. I think that's an important distinction that needs to be worked out through you and the physical therapist; you being the total join patient, and your physical therapist. There are things when patient's say to me "That really hurts." My first question is "Where?' Because a lot of times it doesn't have anything to do with their total joint. They're like, "It hurts right here in my muscle." Great. That's what I want. That's perfect. I'm fine with that. And they can't believe I'm excited for them because it hurts. But that's perfect, and a lot of times I think that's the educational piece. It has nothing to do with the exercise.