RECOVERY MATTERS – a BLOG about Knee Replacement Health This is an educational essay designed to help patients who are facing challenges with their knee rehabilitation at home or in an Outpatient PT setting. We want to acknowledge the valuable contributions of Jason Shepherd, BScPT, Injury Prevention Consultant to this article. For more information about Jason and his practice, click here.
The Nemesis to Traditional Knee Rehabilitation – How to Avoid PT Pain
Dr. Erik Dolton, PhD, has spent considerable time studying the condition known as Protective Muscle Guarding. Let’s start our quick study of this chronic obstacle to proper knee rehabilitation with his comments. He says, “when the brain senses bony instability or tissue damage in-and-around the knee joint, information is compiled and ‘fast-tracked’ to the brain where a determination is made as to the degree of threat and appropriate response the situation demands.
Layering the area with protective muscle guarding is a common decision handed down by the cortex. A protective spasm is the brain’s reflex attempt to prevent further damage to injured tissues. By ‘splinting’ the area with a spasm, muscle ‘locking’ effectively reduces painful joint movements. The brain simply acts to protect the body. “When in question, lock the muscle.” Helping patients avoid PT pain is a major concern of Physio Therapists for knee and other surgeries.
At the most basic level guarding occurs when your therapist pushes your knee one way and you push right back, negating his attempt to help you gain flexibility as you try to protect yourself.
Today’s physical therapist will always be confronted with the mysteries of muscle guarding. And it must be dealt with quickly as continued guarding inhibits proper knee rehabilitation. A therapist cannot administer effective therapy if a patient’s protective muscle guarding stops the therapy dead in its tracks. And often times in addition to the brain’s instinctive reflexogenic response to incoming potentially painful movement, there is the natural reaction to consciously protect oneself from danger. Getting past muscle guarding can be the difference between success and failure (and some unpleasant consequences) for your rehabilitation.
Let’s examine a very interesting concept from Dr. Thomas Hanna, Phd, called sensory-motor amnesia (S-MA). Dr. Hanna writes:
“It is my understanding that perhaps as many as fifty percent of the cases of chronic pain suffered by human beings are caused by sensory-motor amnesia (S-MA).”
This new term, Sensory-Motor Amnesia, which Dr. Hanna coined for descriptive purposes, refers to a condition often present in cases of chronic pain. Its most common sign is poor muscular control caused, not by damage of muscles or the brain, but by brain conditioning following injury, surgery, or long-term stress. The person no longer has an accurate sense of movement and position, of which muscles s/he is holding tight and which are relaxed. Some areas of the musculature have too much sensation (pain) and some areas have diminished sensation. Some are too tight and some are too loose. Some kinds of movement are easy to control, others difficult. The pain of S-MA results primarily from chronic muscular tension and soreness (fatigue); additional pain may come from resultant joint compression and nerve entrapment (paraesthesias).
This loss of muscular control occurs either from the immediate shock of injury (and a “disowning,” or withdrawal of attention from, the injured area, as in cringing), from the physiological memory-imprint of the injury and the habituated action of recoiling as if the injury is presently happening, or from long-term movement patterns (as in limping, long-term nervous tension, or repetitive actions) which lead to the formation of a new muscle-movement habit that the person cannot easily break.
S-MA is a state of habituation, rather than a state of injury (i.e., a lesion). Tension and movement habits cannot be changed by drugs or surgery (which is why standard pain-management methods are so often only partially or temporarily effective with chronic pain); habits can be changed only by new learning — in this case, by developing or reactivating neural pathways for free voluntary movement with an accurate sense of movement and position. The process involves learning or relearning muscular control, whatever the clinical method employed, and a shift from reflexive action to voluntary control.
Relaxation occurs as control improves. With relaxation, pain ends while control remains.
Case Study: “Protective Muscle Guarding and Recovery from ACL and Micro-fracture Surgeries”
Patient: Luis O., New Jersey
Condition: Weeks Six through Nine Post Surgery
- Range of Motion: 75º
- Left Knee (Seated) AROM/PROM
- Flexion: 73º/75º
- Extension: -9º/-5º
- Antalgic gait pattern with 2 crutches (No Left hip or knee extension, forward flexion thru hip and trunk, no functional heel strike or toe off)
- Grade 3 Left knee joint effusion
- Mild, pitting edema into Left anteromedial tibia (proximally)
- Mild-moderate atrophy Left gastrocnemius (medial/lateral)
- Moderate atrophy Left VMO muscle
- Left quad lag
- Mild scar tissue adhesion distal portion of surgical incision site
Luis O. found that his response to the administration of physical therapy was to “resist with all his might” in order to “protect himself from pain.” His physical therapy post surgery had completely stalled. “We hit a wall and I became desperate,” said Luis O. As much as he respected his physio team he was no longer making progress.
At nine weeks post surgery his condition had not changed and he engaged X10 Therapy to help him catch up on range of motion with the X10 Therapy Machine. His performance on X10 was immediately better than during PT Sessions.
Patient On X10
After completion of three weeks on the X10 (by week 12 post surgery), including three 30-minute sessions per day utilizing 7 lbs. of pressure modulation, Luis O. was able to achieve the following:
- Left Knee (Seated) AROM/PROM
- Flexion: 98º/114º
- Greatly improved gait pattern with no crutches (pain-free)
Luis O. began using the X10 Knee Therapy Machine in his home 3x per day, 30 minute duration for each session. His quest to avoid PT pain began in earnest. He found that because the X10 machine was under his control, he trusted that it would not hurt him. His brain (both subconscious and conscious) accepted this fact and he was able to relax during therapy. This allowed for real progress to begin again toward his range of motion goal of 130º. In three weeks Luis was able to gain 39º range of motion. He began walking as many as seven miles with less and less of a limp, at first using only one cane (vs. two previously) and then cane free.
The reactions at both Luis’ PT clinic and at his surgeon’s practice (Dr. Deepan Patel) were very positive. To be fair they were somewhat incredulous as his progress exceeded all expectations. Luis was able to avoid a Manipulation Under Anesthesia as his ROM exceeded the lower limits his surgeon set for M.U.A. Luis was able to overcome guarding, avoid PT pain, and get back on the path to recovery.
If we reference Dr. Hanna’s description of “the formation of a new muscle-movement habit that the person cannot easily break”, we have an accurate representation of Luis O.’s condition prior to starting X10 Therapy. Through the use of the repetitive motion on the X10 Knee machine, motion that is controlled fully by the patient, Luis O. was able to achieve relaxation “as control improved.” And as his pain ebbed his control remained as Dr. Hanna suggests will occur. It was only after Luis O. “trusted” that the X10 would follow his direction, never move past comfortable range of motion, only advance degree by degree as his leg became relaxed could avoid PT pain, that he began making significant gains. He overcame his own Protective Muscle Guarding which led him to a successful rehabilitation on the X10 Knee Rehabilitation Machine.