Knee Replacement Pain Management
Mary Elliott interviews PT, Amy Bodway
Below are highlights from Amy and Mary’s conversation about knee replacement pain management. To listen to the interview click the Play button above.
Pain and Knee Surgery Recovery
Pain and recovery go hand-in-hand. When we’re talking about a surgical situation, there’s no way around the fact that there is going to be some degree of pain. Expecting that helps you to be prepared. It’s a daily changing entity, and you have to constantly be adapting and changing and listening to what your body is telling you, based on a change in your activity. If you don’t have good pain control, good pain management, your recovery is going to be more difficult.
No one wants to hurt and that’s one reason we want good pain management. When you hurt to the degree that you can’t participate in your rehab, if you can’t participate and in your physical therapy, you’re not getting the most out of your recovery. That will impact your long-term outcome.
The Importance of Range of Motion
The biggest challenge in rehabbing a knee is to increase range of motion. It doesn’t come back spontaneously. You have to put in time and work to get it going. Pain will cause you to tense up and guard and resist the efforts to increase your range of motion. There are a lot of different things that we can do to help manage that pain. It’s not just one individual strategy.
Solving the Pain
Here are the basic tools:
A combination of oral medications that your physician may have ordered, whether it be over the counter or narcotics and stronger medications.
Icing your knee regularly and elevating it above the level of the heart.
Balancing your activity (having periods of rest with periods of activity)
- Too much rest is not good. You’re going to get stiff and have trouble bending
- Too much activity is also not good because you’re going to aggravate your pain after knee replacement. There’s, there’s a significant surface area of bone that’s removed and that bone is trying to heal.
- If you even stand for too long at one time or if you walk for too long, you’re going to have more pain. That pain can translate into additional swelling because the pain is a reaction to that. Excessive activity and the swelling will increase as well and in turn that can set your ROM back.
In a nutshell:
It’s finding the balance between the timing of your pain medication, icing and elevating, and finding the balance of periods of rest and activity to control the pain.
There will be Pain
In the immediate days after surgery it’s unrealistic to not expect some degree of pain. We want to control it and manage it and stay ahead of it. Those are terms that you’ll hear. To ‘stay ahead of your pain,’ just means not waiting until the pain is an eight out of 10 to take the pain medication. It’s taking it when it’s creeping up to a three or a four, taking it in advance of your home or outpatient therapy visits to prepare you to tolerate the rehab.
Finding Your Limits
Finding your tolerance or your threshold is twofold.
- It’s listening to what your body is telling you, how much you feel, where your stretch is, how much you can handle.
- It’s also ‘pressure modulation.’ That means sensing the tension and the resistance in your leg. Sensing the weight of your leg as it has to move against gravity.
On the X10 Knee Recovery System™ you can see as you’re using the program and advancing through your range of motion that the pressures might go up because the X10 machine senses the resistance in your leg. If you want it to go further, you can give it permission to use more pressure and that can help you to know when you are reaching the end of your knee’s tolerance for that session. It is when the pressure creeps up that you and the machine know that you are reaching the knee’s current limits, your sensation of stretch.
Dealing with Rehab Discomfort (not Pain)
As you progress on range of motion sessions it can get more intense: it can border on being painful. And we never want to work to that point of pain because that’s your body telling you, “I’m at my limit, I can’t go much further.” If you force it, you’re going to aggravate your swelling and it’s going to set your ROM back. So, the pressure that the X10 machine is sensing and it’s giving you that feedback helps you to know where your knee is at and where that resistance point is. It allows you to find the balance of advancing, but not pushing too far past what your knee can tolerate.
Compared to Traditional Physical Therapy
In traditional therapy, a disadvantage is that, as a physical therapist, you’re just not able to see your patient every day, three times a day. So you’re not getting as much hands on time. You can’t have as much therapy time. In the traditional sense there is the benefit of the skilled clinician feeling and sensing the resistance. It’s coming from a patient’s leg as they work through the range of motion. So, you develop with experience the knowledge to know when and how to push into a point of stretch. But you also can sense where it’s too much resistance and you’re going to stop and hold it for a little while. And you may guess on range of motion in, in therapy, but you’re doing additional things during the time that you have the patient in an outpatient setting. An ideal situation is to have an hour with the patient.
In that hour you’re doing some manual hands-on, you’re doing some joint mobilizations, you’re doing stretching, but you’re also working on their walking quality, their gait. You might be working on technique with stairs. You’re working on strengthening, you’re working on balance. The trouble is you just can’t dedicate too much time to that range of motion.
Whereas when the patient is doing it in their home at their convenience, sometimes it’s eight in the morning or at two in the morning. Whatever fits with their day and how they’re feeling. In total they spend more time working on the range of motion. I think that’s a big reason why patients progress, more rapidly when using the X10, they can gain more range of motion with less discomfort because, with traditional clinical therapy, you only have so much time. You’ve got to kind of push it and just muscle through it. And that can induce more pain and more resistance. And sometimes even more pain and swelling the next day.
Knee Replacement Pain Management
With the X10, you have a half an hour or longer on each session and you’re creeping up on that stretch. You’re working into it slowly. You’re holding it, you’re letting it release and then you slowly progress. In the first session of the day you’re going for better than you did the day before. In the middle session you’re going for a little bit better. It’s just so gradual and incremental. That it’s a big part of why patients are more comfortable, but it’s also why they actually progress further on the X10 because of the time that you spend doing it. And by not stimulating that pain reaction of the patient, by going too fast, you’re not guarding and resisting, and that also helps you go further. So there are positives to the X10 in the time that the patient can spend dedicated on the range of motion that in an outpatient setting or even in home health, you just, you can’t address. And when you’re in control of a movement of your leg, I think you’re much more calm.
Calm, Relaxed, Focused
Being in control of rehab, being in control of when to push further keeps patients calm. It keeps them relaxed because if you do tense up, you’re going to fight against yourself. You want to do it when your body is ready to go forward. The patient is in control all the time with the X10. If you want to advance and then you realize, “You know what, wow, that’s more stretch than I bargained for, I didn’t think it was going to be that tight,” you can always back down. Just like there’s an up arrow, there’s a down arrow and the patient can go back if they realize that they have pushed themselves too far. In traditional therapy you kind of put your trust in the therapist and you hope that they’re going to do what is right for you.
And there are always varying degrees of quality of background and experience and approach with the therapist that you have. Some will explain what they’re going to do and you can trust them. Others will think that this person needs to go further, so I’m just going to push them and take them there with no warning. And that kind of surprise, that quick movement, can cause you to tense up and relax and it can work against you.
Little Time: Lots of Time
When you compare a machine that is in your home it’s just a different path, a completely different path and can take a totally different approach to your healing.
With any physical therapy you have a limited number of visits, a limited amount of time spent with that therapist. They’re going to give you exercises to do at home. But if you’re trying to do a self-stretch at home, sometimes they’re difficult because you have to use your arms or your other leg to assist your surgical leg to bend. And it’s hard to relax for the stretch if you’re actively trying to give yourself that stretch. So sometimes those self-stretches are not as effective as they are if it’s the therapist or the machine giving it to you. And then also you don’t have the feedback when you’re doing your exercises on your own. You might try to be sitting in a chair and pulling your life back or planting your foot on the ground. And scooting your hips forward in the chair to give more stretch. You kind of look and you think, I think that’s better than I got yesterday. It looks farther, but you’re really just guessing.
With the X10, it’s objective. It’s measuring you in degrees so you know exactly where you’re at at any point in time. And you can compare to where you were a week ago, a day ago, and it can help you stay on track and know, “Okay, I’m doing well, I’m progressing,” instead of kind of being in this limbo where you’re just doing your best. Of course you’re trying, but you just don’t have that same degree of feedback, that the X10 can give you.
And I think that is again, a reason why patients with X10 are successful because they know where they’re at at all times and they get that feedback in real time.
The X10 Meta-Blog
We call it a “Meta-Blog.” We step back and give you a broad perspective on all aspects of knee health as with this article on ‘Knee Replacement Pain Management’.
In this one-of-a-kind blog we gather together great thinkers, doers, and writers. All our work is related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, patients, and as many smart people as we can gather to create useful articles for you. This is for you if you have a surgery upcoming, or in the rear-view mirror. Or maybe you just want to take care of your knees to avoid surgery. Executive Editor: PJ Ewing
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