You wake up in the recovery room following the surgery and feel great. Relief washes over you knowing that you’ve finally done it. Smiling you nod off to sleep and they take you up to your room.
Now what?
If phase one was years of dealing with knee pain, having a hard time walking, finally coming to the realization that you need a replacement, actually scheduling it and showing up, then phase two begins now. Likely your surgery was in the morning and by afternoon they bring you a lunch plate. The knee still feels great as the medications and or the nerve block are still in full effect. Soon, physical therapy will come to the room, introduce themselves and tell you it’s time to get up and walk. They bring a walker and a belt to put around your waist so that you don’t fall if you get queasy, weak or simply can’t stand up quite right. Usually that first walk is to the bathroom or to the door and back, possibly further if you feel like it. You get back into bed and it feels good as you’re tired. Therapy will hand you a sheet of exercises similar to the ones you’ll find at the end of this article and hopefully run through those exercises with you.
I recommend that you print these off as they are the standard exercises given by most surgeons and therapists to most patients. (Possibly some slight differences and if your surgeon or therapist gives you different exercises, you should obviously use those). In practicing them prior to surgery you’ll be better prepared to do them after surgery. This same pattern of therapy walks and exercises will be repeated for the next 24-48 hours until they send you home.
Going home:
Hopefully you’ve seen my other blog posts and read the post re: what you should do before surgery which includes home prep, meal/grocery prep and many other suggestions. It will make going home much easier. If home health hasn’t been ordered please ask your surgeon to order it for you. You’ll need another set of eyes on you and having nurses and physical therapists working with you will speed your recovery and improve your safety if something isn’t going quite right.
So what should a normal day look like? It’s better to get into a routine and let’s start with:
Pain medications
First and foremost this is a painful surgery. Respect that. If you need the medication, take it. And it’s better to be on a regular schedule. Frequently people want to wait until pain levels start to rise before taking their meds and this is a mistake. In the medical field we refer to it as being behind your pain or chasing your pain. If you’re behind it, it’s hard to catch up. You’ll want to stay on a regular schedule for the first two weeks. Usually doctors will order 1-2 pain pills every 4-6 hours. Figure out what frequency works for you and stick to it. You’ll sleep better and be able to move around and exercise more if you’re not hurting as much. No one wants to stay on opioids long term and it’s fine to start getting off of them as soon as you can, but the first two weeks are rough and regular pain medications will help. ***A quick side note re: pain meds – they can cause constipation. Everyone is different, but you will likely get constipated if you aren’t used to opioids so plan accordingly, speak with the surgeon and have foods/medication on standby if needed. Many surgeons prescribe a stool softener after surgery.
Icing and elevation
I tell my clients that they need to lie down in bed, with their leg elevated on pillows(higher than their heart and no, recliners don’t count) and with an ice pack a minimum of six 30 minute sessions a day. This will decrease swelling, decrease pain levels and improve healing. The more swollen you are the worse blood flow is (congestion) and the more pain you have. More swelling = more pain/Less swelling = less pain. It’s as simple as that. Set a routine and stick with it. If you have a CPM (continuous passive motion machine) coordinate your ice and elevation sessions with the CPM. Get in all 6 hours of the CPM if it’s been ordered for you.
Exercise/Walking
Twice a day is preferred for your exercises. You may have received a set of exercises from your surgeon or PT and if not click the link at the end of this article and print those. Perform your exercises twice a day and try to get as much bend and straightening as you can while performing them. These exercises really aren’t designed to build strength, but rather to wake up your leg muscles that are still in shock from the procedure. Frequently people will look at their leg and say “It’s not moving like I want it to.” All normal, just push through. For walking, try to get up frequently (1-2 times an hour) and take a lap around the house. We want you walking frequently but not so much you increase your swelling.
Sleep
For the first two weeks sleep will be a bit rough. Get what you can. We move around when we sleep and when you move normally at night you’ll wake up due to the discomfort. Sleep improves after the first two weeks. Just grab as much as you can.
Other notes:
Keep your incision dry
It’s likely you’ll have a silver impregnated dressing covering your incision. If you have a dressing leave it unless instructed to remove it. Do NOT apply creams, balms, salves, vitamin E oil or anything to the incision. Do NOT soak your incision. No baths, pools or hot tubs. If you have staples they’ll be removed between day 10-14. Even after the staples are out you won’t want to apply anything to your incision until it is free of any scabbing (even little ones) and completely closed. Call your surgeon or therapist with any questions. If you run a fever higher than 101.5 degrees, call your surgeon. Some surgeons protocols are different ie: 101 degrees, but high fevers need to be reported immediately.
Clot prevention
A very real potential issue are blood clots and you don’t want one. You’ll either have compression hose, prescribed blood thinners (sometimes an injection), or both. If you’re supposed to wear hose, wear them. If you’re prescribed blood thinners, take them. Clots don’t happen often, but they can, so please do your part to prevent them.
I’ve been a physical therapist (PT) for 24 years. Good for me right? No, good for you! This means I get to share things I’ve learned and you get to keep your $25-$75 (…or sometimes more) co-pay. In this article I’d like to discuss falls, mobility and maybe, just maybe, how to live a bit longer. First of all, what is mobility? By definition mobility means “the ability to move or be moved freely and easily,” but I’d like to drill down and be a little more specific. Today I’m talking about joint mobility. Everyone knows that as we age our joints don’t move as well as they once did. This can begin the slow decline of “I’m not moving as fast as I used to”, followed by “I’m not moving as much” and then comes “It takes me longer to get around…” Eventually you’re moving less, you’re losing strength and you’re losing the ability to move around as you want. So begins the downward spiral…can you see the tiny little whirlpool above the bathtub drain and hear the sharp little sucking sound?
Wow, that’s depressing! There is hope. Please read on.
All this “not moving as well” and “decreased joint mobility” that we accept as we get older puts us at a higher risk of painful joints, loss of strength, more falls, inevitable fractures and a shorter life span. Not good… not good at all. I’m privileged to work with a wide variety of clients of all ages. I used to be surprised by the lack of joint mobility I would find in people in their 30’s and 40’s, but not anymore. Sad to say that nowadays I expect to find a lack of mobility in my younger clients ankles, hips and backs. It becomes even more restricted in older adults.
Let’s talk about the hips for a second. They are the second most mobile joint in our body only beaten out by the shoulder. Our hips are made to move in every direction, even to rotate on their axis. Quick question…can you sit Criss-Cross-Applesauce? It requires hip flexion and “external rotation”, (a big $10 word that we PT’s like to use when we’re trying to sound important) which means rolling the thigh outward. If you can’t, you should start. Try it while you’re watching TV. Lean back on the sofa and pull those tootsies up into your lap, let your knees drop down and feel the stretch. Better yet, sit on the floor in front of the couch and try it. Get those hips opened up; your back and knees will thank you.
“OK, so what’s this about a shorter life span? Are you saying that because my hips and ankles aren’t loosened up I won’t live as long?” No, I’m not saying it. In a study published in 2012, Dr.’s Leonardo Barbosa Baretto de Brito Claudio and Dr. Claudio Gil Soares de Araujo, et al, say it. For their study, participants aged 51-80 took what they named the “Sitting-Rising Test.” Study members would stand in the middle of an open area, get down to the floor and then get back up. Pretty simple, yes? Possible 5 points on the way down and 5 points on the way back up. Every time a hand, elbow, knee or any part of the body was used for stability or to push, a point is deducted. For example if you put two hands on the floor to get down, that’s a 2 point deduction. If you use a knee and a hand to get back up to a standing position, that’s another 2 point deduction. In this example you’d score a 6/10. The long and the short of the findings are that for every point drop in your score, your risk of dying increased by 21% over the next 6 years compared to someone scoring higher. In this example, your score of 6 puts you at a 42% higher risk of mortality in the next six years than someone scoring an 8.
Having said all of that I don’t believe the study is all encompassing, there are a great deal of variables and maybe even a few flaws (as can be found in all scientific studies). The study was large (over 2,000 people), looked at “all cause” mortality, (meaning if you flamed out on the highway due to an 18 wheeler smashing you, it still counted), but they collected a lot of data. With a study group that large you will begin to see trends. I’m not here to debate their findings, but I will say even if they’re only half right it presents a strong argument for working on your flexibility and strength.
Working on your flexibility and strength doesn’t have to be a major undertaking. Even the simple act of getting down on the floor and getting back up will do it. Ask anyone over the age of 60 “When was the last time you got on the floor?”. I ask this of all my patients over the age of 50. My favorite response of all time was “Do you mean voluntarily?”. Yes, voluntarily, when was the last time you got down on the floor? The usual reply is “I can’t remember.” or “I get down to play with my grandchildren but I have to scoot over to the couch so that I can get back up.”
Falls are a huge problem in the US (and the world). I don’t have the data to back up this next point, but let me ask you. Who is more likely to fall? Someone that actively gets up and down off the floor 10-20X a day, or the person that never gets on the floor and hangs onto furniture as they walk throughout the house? To be fair, there are many potential causes of falls in older adults, poor eyesight, poor hearing, medications, illness, diseases (think Parkinson’s, Diabetes or Stroke), throw rugs, comforters draped off the end of the bed…the damn cat. I’ll bet you $1 that someone who is used to getting up and down regularly is less likely to fall and more likely to get back up after said fall (barring serious injury, yes, I’m looking at you hip fracture) than someone who hasn’t been on the floor in months, voluntarily.
If you, dear reader, are feeling like you’re not moving around as you’d like or have a real fear of falling and want to begin, please check with your doctor or PT first. If the thought of getting on the floor and back up is scary, then I’m talking to you. Get with a PT that can assess you and teach you how to do it safely. If you’ve had a knee or hip replacement, it doesn’t exclude you, but you need to be careful. You’ll need instruction, seek it out.
If your thought is “What a pain in the a$*, I don’t need to do that!” then you NEED to begin. Clean your baseboards, hit a yoga class(es!), sit and watch TV in front of the couch “criss-cross applesauce”, simply get up and down 10X in the morning and 10X in the evening. Heck, do a Turkish Get Up! (I have no affiliation with www.exrx.net, simply like their explanatory video) The Turkish Get Up is my favorite “all body” mobility, stability and strength exercise. Perform two of them on one side and two on the other. Just do it without a kettlebell or weight until it gets easier. Much better than Burpees. (I love hate you Burpees).
There you have it. It is vitally important that you stay mobile and strong as you age. Falls suck. Lying on the floor for a long time after you fall, sucks. Hip fractures suck. Surgery sucks. Being scared of falling sucks. Spending a few minutes a day working on your mobility/strength, being more confident when you walk, reducing your risk of falling, putting yourself in a position to get back up after you fall, and maybe even living longer, most decidedly Does. Not. Suck.
That was my exact question going into the continuing education course I attended in early October. Obviously it’s about getting poked with a needle, but what does it do? What are the benefits? Does it hurt? How is it different from Acupuncture? Why is it dry?
The course I attended is based on the teachings and studies of Dr. Yun-tao Ma of the Integrative Dry Needling Institute. The purpose of this article is not to discuss what was learned, but rather to share the benefits of the therapy.
What is “Dry Needling” and how does it work? (This is taken from a patient information handout authored by Integrative Dry Needling) :
“Integrative dry needling is not acupuncture (traditional Chinese medicine), it is based on neuro-anatomy and modern scientific study of the musculoskeletal and neuromuscular systems. A very fine filament needle is inserted through the skin and into the deeper tissues that are considered trigger points to your pain. Dry needling works by causing a micro lesion within the pathological tissue thus breaking up shortened tissues, inhibiting a reflex arc from the nervous system to the tissue, normalizing the inflammatory response, and centrally mediating the pain. This mechanical and neuromuscular effect provides an environment that enhances the body’s ability to heal which ultimately reduces pain.”
What are the benefits? As noted above by normalizing the inflammatory response, inhibiting reflex arcs and mediating pain, people receiving the therapy can enjoy improved range of motion, increases in strength, decreased pain levels and many other health benefits.
Does it hurt? The needles used for dry needling are very thin, think human hair thin. Sometimes people feel a slight sting when the needle enters the skin. As the needle is advanced sometimes people will describe different sensations, such as a muscle twitch. On a personal note, with several of the needles I felt what would be described as a deep and mild ache. This is actually desired and let’s the practitioner know they are in the right area. Over the course of the this past weekend I was “needled” close to 80-90 times. I can guarantee that I said “Is the needle still in?”, more than I flinched or said “I felt that.”
Why is it called “Dry Needling?” If you receive an injection, say at a doctors office or a flu shot at the pharmacy, a medicine is being injected. You have fluid being inserted into the body. This is “wet.” In the case of “Dry Needling”, no medicines or solutions are being injected, quite simply a “dry needle”, hence the name.
I can vouch for the decrease in pain levels. I was the class guinea pig for the section of the course that involved lower leg needling. I was needled 8 times from the knee down on my left leg. I personally didn’t experience the immediate relief that many people get, but when I walked into the clinic Monday morning I literally begged a co-worker to needle the same spots on my right leg. The difference was that significant.
The bottom line is that I’m extremely excited to be able to be able to offer this service to my clients. Since attending the course I’ve been able to offer this therapy to several people and I’m excited with the results so far. I’m not going to tell you that it’s for every client or for every condition, but for those it can help, good things are coming.
A lot has led up to this. You’ve been hurting for months and more likely years. You’ve had a knee scope surgery as it was required by Medicare before your replacement. You’ve been limping along both dreading the procedure and filled with hope that you’ll be able to get around without the pain that’s been limiting you for so long. So what do you do now?
You’ll get to that point, but first you have to respect the surgery. Your recovery will be measured in months, not days or weeks. Knowing this will help you settle into a routine.
You must have equal time up and down. What I mean by this is if you’re not in bed with your leg elevated it counts as “up” time. “Up time” is walking, eating at the kitchen table, sitting on the couch, riding in the car for your post-op staple removal, going to your grand-daughters dance recital,…whatever… Any time your knee is lower than your heart it’s “up time”. The circulation in your operated leg is diminished following the surgery and when you’re “up” your leg is going to swell more and thereby hurt more. (More swelling = more pain… this can’t be emphasized enough!)
By “down,” I mean in bed or on the couch with your knee higher than your heart and your ankle higher than your knee. Recliners don’t count since your rear is the lowest point and your swelling won’t go down. The fluid will stop at the lowest point (your butt) and back up into the knee.
Equalize your “up” and “down” time and you’ll have a much happier and less swollen knee. I’ve had a lot of patients over the years that will be cruising along two weeks out of surgery, and will go on an outing. After being up for 6 hours they get home and they’re miserable for the next 24-48 hours because their knee is much more swollen. Respect the surgery and give your knee equal time.
You’ll need to do your exercises twice a day (or what ever your surgeon or therapist has recommended). If you haven’t been provided with exercises there will be a link for a sample set of home exercises at the end of this article. Please run these by your surgeon for his/her OK before attempting them. They are the standard exercises that are performed in the first week or two following replacement. Please keep in mind that these exercises aren’t designed to build strength, but rather “wake up” the muscles in and around your knee that are in shock and not working properly following the trauma of surgery.
You’ll need to ice your knee regularly (no less than six times a day, preferably more, and 20-30 minutes at a time). I recommend a cold pack here, but a couple of bags of frozen peas or corn works well too. One on top and one underneath. Just make sure that you protect your bare skin with a pillowcase or towel!
If your surgeon has ordered a CPM (continuous passive motion) machine please use this for 6 hours (or the surgeons protocol) per day. Most people I work with do a 2 hour session three times a day. Some surgeons don’t order CPM’s and that’s fine as I don’t think there are any studies that show long term benefit, but I think there’s a lot of short term benefit. It gets you in bed and elevates your leg (think “down time” my friends) . You can even throw a bag of frozen peas or a ColPac ice pack on your knee and the combination of elevation, gentle motion and cold can be a little slice of heaven.
Blood clots and preventing them. They are an uncommon side effect of the surgery, but blood clots can be a serious and fatal one. Most people are placed on a blood thinner such as a daily aspirin, a prescription medication like Eliquis or Pradaxa or at least wearing those white compression hose that seems like they were designed for a 20 pound toddler. Please use whatever your surgeon recommends and follow those recommendations to a fault.
Here’s link to a sample set of exercises that should be reviewed by your therapist or surgeon prior to attempting them.
Side note…If PT hasn’t been ordered, get on the phone and ask your surgeon to order PT. You need an ally in your recovery and a physical therapist is just what you need! These exercises are nothing crazy, just good movement and range of motion.
http://www.my-exercise-code.com then enter code Q9L9UBF
If you have any questions please feel free to reach out to me at www.chriseastonpt.com.
Thank you, and may God continue to bless you!
Chris
***This blog post is for informational purposes only and is not meant to replace the advice of a surgeon or your physical therapist. Please consult your surgeon re: all information included in this article.***
You’ve made the decision to have your knee replaced. You’ve met with the surgeon. Your lab has been ordered. You have to go to the hospital (or your family doctor) next “Tuesday” to have your blood drawn for labs. Your surgeon might want you cleared by a cardiologist. All the OFFICIAL medical wheels are set into motion so that everyone else is prepared for your replacement.
What about you? Are you prepared? Physically? Mentally? Is your house ready? What about the dog?…
There’s a lot that goes into getting ready for a major surgery like this. There’s a lot to think about, but some pre-planning will make the process easier.
First off you have to realize that you’re going to essentially be out of commission for about 3-4 weeks. Ignore the stories of your neighbor who had it done 2 years ago and was out mowing the yard and golfing in a week. That’s simply not true, and if he did, you didn’t see him rolling around in bed for two days miserable from all the excess swelling. Respect the surgery. It IS a BIG deal and you need to honor that.
OK, so keeping that in mind make sure that:
All your shopping is done and you’re stacked up on groceries. And yes, that also counts if you don’t do the shopping. I’ve heard many spouses over the years say “I didn’t know what I was getting into, and I didn’t even have the surgery.” Having shopping done for at least two weeks (and meals prepared in advance, think frozen casseroles) will be such a relief later on.
All laundry is done and bed linens are clean and changed. You’re not going to be able to do laundry or change your sheets for at least 2-3 weeks and clean linens are always nice!
You have ice packs at the ready. On my website I have a link to Amazon for a Col-Pac brand ice pack that I love, but you can also use a big bag of frozen corn or peas. If you’d like a recipe for a home-made icepack, message me and I’ll send you the recipe. Make sure your knee is protected by a towel and ice that baby no less than 6 times a day, yes 6! (20-30 minutes at a time).
Make sure your house is clean and vacuumed. “I hate looking at all that stuff on the carpet and I can’t do anything about it, it’s driving me nuts!” I’ve heard that more times than I care to hear and have gotten out someone’s vacuum on more than one occasion.
Please make sure all throw rugs are up, your bed comforter is up and off the floor at the foot of your bed and the floors are cleared. Trust me, you don’t want to fall after you undergo a knee replacement.
I thought about leaving this out, but I’ll mention this anyway. You will be constipated following surgery. You know your normal rhythm, so plan accordingly. Don’t overdo it, but be aware that this will be a problem. Your surgeon will advise you on what steps to take if he/she hasn’t already.
Hopefully you’ve found this helpful. All of this information (and a lot more) is available in my book “Knee Replacement Surgery, A Patient’s Guide: Before, During & After” available on Amazon. If you have any questions please reach out to me either on FB or here on my website chriseastonpt.com/contact/. I’d love to answer any questions you have or help in any way I can.
God bless
Chris
P.S. I might have mentioned the dog earlier. Make sure Fido is stocked up on food as well. Those bags are heavy and having it on hand is nice. Dogs (and cats) can be fall hazards too, so please be careful!
