Two knees and a hip

When a rehab expert has a hip replacement

Our good friend, recently retired physical therapist John Barbis, and I have previously written about his total knee replacements (here and here). They have been two of our more popular posts, especially with people who were seeking more information about the surgery. John has just had a total hip replacement (he will be totally synthetic one day!) and I have just interviewed him:

John, what kind of hip replacement did you have and when did you have it?

I had a classic posterior-lateral approach on 8 January 2016.  My surgeon gave me the option of having any of the three current procedures. He has done hundreds of all three procedures, but he has done the classic for more than 35 years. We discussed the pros and cons of the three (possible femoral nerve injury with the anterior approach; abductor muscle weakness with the lateral; and larger scar, potential longer recovery, and potential for dislocation with the posterior. He thought given the images of my hip and the good history of my knee replacements, that the longer recovery and dislocation potential were offset by his ability to better view the tissue and place the prosthesis. Besides you can not beat the track record of the traditional approach if you are healthy and motivated.

Why did you have a hip replacement?

I have had intermittent pain and popping in the groin for about 25 years. I am sure that I had a torn labrum from wrestling. Every 5-6 years I would do something and it would return. Over a period of about two weeks, I could manipulate it, stop the popping, and pain would resolve until I did something to it again. Last July, I misstepped coming down a ladder. My right foot was on the third step from the bottom, but my left missed and my foot went right to the floor producing an intense extension compression moment that nearly caused me to pass out.  I managed it and it seemed to be improving slowly until September when it started to give me real problems. It became increasing painful to walk, sit, and lie down. Extension was painful, hip flexion pain came on at about 90 degrees, and any adduction was intensely painful. The only way that I could sleep was on my back with my legs elevated so that my hip was in a loose packed position. I started using a walking stick in November when I had to walk for any distance more than a half mile. Sudden hip flexion was particularly painful. Sex was becoming increasingly painful!!!

How is it now, and how do you predict it will be in 2 weeks and a month?

Now, at two and half weeks after surgery, the hip is better than it was before the surgery. Last week I was able to walk three miles (through the woods and up and down hills) without using the walking stick. I can sit so that my hip can tolerate 90 degrees for an hour or so (it was barely 10 minutes prior to surgery). Strength and mobility have returned to near normal except for end range hip flexion/adduction. Rapid forceful hip flexion is still painful. Walking in the nearly 30 inches of snow from a recent storm was quite painful due to the amount of hip flexion needed and the small muscles controlling my hip became rapidly fatigued and painful after a short amount of walking. I was able to shovel snow with only minimal pain. No sex yet because of fear of potential dislocation. At three weeks, I figure it is more than worth the try. I can put my socks on and fully dress myself. I did that within 24 hours. Sleeping, as it was with my knees, continues to be the main problem. Prolonged hip extension (lying supine), hip flexion at 90 ( side lying on non-operated side), lying on the scar, and the weight of the covers as I turn over can produce pain that awakens me and makes it difficult to sleep normally.

Two weeks from now- Definitely sex!!!! I plan to be walking 15-20 miles per week out doors in the woods. Sitting tolerance should be up to more than 60 minutes without increased discomfort. I would expect to be back to near full activities and only avoiding those high intensity activities like running, jumping, squatting, etc. out of respect for tissue that may be still somewhat at risk. In a month I would expect to be starting those activities and back to near full activity. If the hip turns out to be anything like the knees, normal sleep will be the final component of recovery. That may be 2 months?

Can you tell us about your pre-operative strategies?

I stayed as active and in as good a shape as possible. I balanced out my activities including some walking, some weight lifting, Tai chi, and balance/coordination activities. I didn’t want to have a flare-up. I dropped my walking down from around 16 miles per week to about 12 miles with the use of a walking stick. I lowered the weights I lifted too.

I actively tried to prevent the development of central sensitization and maintained a varied program including:

– cutting back activity at signs of neural flares and referred symptoms but trying to maintain activity when one appeared

– making sure I assumed good pain free rest positions after activity

– undertaking Recognise knee and back 1-2 times per day

– 20 minutes of mindfulness/ visualization/surgical rehearsal once per day

– starting a low dose of gabapentin two weeks before surgery.

Can you tell us what you are doing now as part of your management?

I began with progressive walking, starting at a quarter mile with crutches, to weight-bearing to tolerance 36 hours after surgery, to walking 2-3 miles per day with walking stick, to walking 2-4 miles per day with only partial use of walking stick (particularly on uneven terrain where balance and more control is needed).

I try to mobilize the femoral, obturator, gluteal and sciatic nerves 2-3 times per day. I did my Tai chi as tolerated for balance and control.  I still do mindfulness/meditation for 20 minutes once per day. I focused on visualization imagery of the hip healing during the mindfulness. With the onset of pain with walking I work on visualizing the hip joint working normally (a mindful type of walking). I can generally stop or greatly reduce the pain when I do it.  I am particularly careful walking outside given the amount of snow and ice that are around. I realize that the one way I can blow this recovery is by slipping and falling. I still balance my activities- my hip still does not feel fully stable in odd positions. I am returning to activities as tolerated using avoidance of neural flares and hip precautions as indicators. Progressive recovery of ROM with passive and motions is proceeding nicely.

In our previous posts you outlined your pre- and post-operative strategies for your bilateral total knee replacements. Do you think the essential elements are the same for hip replacement or indeed any joint surgery.

Absolutely

Any particular advice for a nervous THR replacement customer?

Trust your surgeon and your body. Your surgeon is going to get rid of the problem and put in a nice shiny new joint in there. It will now be yours. Your body will heal nicely but you have to work with it. By body I mean the whole of you needs to work at the healing. Your brain, your nervous system, your immune system, your motor control systems, your HPA axis, the new joint structures, and post surgical wounds all need attention.

I plan on these new joints lasting the rest of my life. I looked at what I did pre surgically and post surgically as investing in the mobility for the remainder of my life. I figure that the care, time, controlled discomfort, and effort put in now will pay off well for many years to come. Others have invested a lot of money and expertise in my hip, I need to invest that and more.

You now have synthetic materials including metal in both knees and one hip. Has this material become part of you and is this concept important in rehabilitation?

Right before the surgery in the presurgical suite, I thanked my left hip for its service. I got a lot of mileage out of it and asked it to do some pretty ridiculous things over the last 67 years. But it was time for it to go just like my old knee joints. This new hip is mine and no one is getting it! The idea that I would not accept them as mine (especially given the pre and post surgical work I put and am putting into them) seems absurd to me. I expect them to service me well.

THRs have been a real blessing for humanity and many Orthopedic Surgeons will say that it is the most successful orthopaedic operation of all time. I would be interested in your thoughts on the following:

If I do a literature search for “total hip replacement” and “brain” or “plasticity” or “imagery” there is little or nothing to find. Yet your pre and post op management strategies have involved much imagery and activity which targets the brain. Most physical therapy post-op strategies appear very biomechanical.

Joint replacement surgery has been in sole control of orthopaedic surgeons and physical therapists. Both groups tend to be “boneheads” (both in the good and bad connotations). I want a particularly good bonehead to do the procedure and to understand the tissue necessities required for good function of the joint and the tissue around it. Those boneheads are good. The bad boneheaded part of this monopoly lies in the traditional inability of both groups to look past the tissue and see the biopsychosocial components required in returning a patient to full function. There is good outcome research now demonstrating that the 20-30% of patients who have less than optimal outcomes from joint replacement surgeries have those poorer outcomes not because of a joint or muscle problems. Behavioral, central/peripheral neural sensitization, and elevated neuroimmune responses come into play. This does not relate to just joint surgeries but to cardiothoracic, vascular, cancer, gastric, and pediatric surgeries as well. In these other surgeries imagery, mindfulness meditation, and behavioural interventions before surgery are well studied and important for improving outcomes. Orthopedists and PT’s have been sufficiently boneheaded to be wilfully blind to the reasons for that not insignificant group that does not do optimally and have avoided applying the research from other disciplines.

Patients with THR often report that there is a spectacular reduction of pain post THR. Is pain really generated in the brain?!

Again the problem comes in defining pain.  The vast majority of the population of patients and health care providers still do not understand the differences between nociception and pain. In meditation, mindfully walking, etc. my brain could often turn off nociceptively triggered pain.  There is a lot of nociceptively triggered pain when you’ve got a bad hip or knee!  I could turn it down and even off with mindful effort or in the engagement of my neural bandwidth with other activities. At other times when I moved poorly, maintained an impinged position, it could hurt and I could not stop it.

At times while walking with a misstep I would experience pain that made me nauseous.

A THR can offer the potential for massive life changes, yet I believe (and there is a bit of data on this), that many people don’t realise this and are missing out.

My knees were a life-saver for me. I found myself, even with doing all of the right rehab and other stuff, losing myself through the inability to be active at levels that were essentially me. My knee replacements have given me that back. The last 5 months, as the hip became worse and I became either less active or more cautious, I felt that part of me slipping away again. (Loss of sexual drive due to pain and stopping fly fishing because wading was too painful were sharp reminders) In many ways the hip was more disabling than my knees. Already I feel that the me is coming back.

What else would you like to tell us?

Having your joint replaced is not a walk in the park. Anyone doing this needs to look at this as an investment in themselves that requires time, effort, perservance, and a willingness to endure curative discomfort.  I could not conceive how I would be functioning now without these procedures. I want to thank my surgeon for his expertise, but I also take great pride in what I have done for my future.

 

My thanks to John for sharing his expertise and unique experience once again. I hope that for anyone considering a THR, John’s story and advice will help them to make the best decisions for them, while also helping them to realise that a THR is not the end (or even the start) of their recovery, but one part of a larger, ongoing, more biopsychosocial process.

-David Butler

NOIgroup is teaching around Australia in 2016 – supercharged 3 day combined EP and GMI courses in Townsville and Noosa, PPR in Adelaide, and details to come on our teaching visits to The Australian Institute of Sport in the Australian Capital Territory, and Perth

 

13 Responses to “Two knees and a hip”

  1. rsser

    Thanks. Speaking as a layman and patient there’s a lot to think about in this account.

    Reply
  2. EG Physio

    afaik, THR/TKR have not been compared against placebo surgery, so we don’t really know why people have such immediate and complete pain relief with these interventions.

    The weight of available evidence for surgery *generally* suggests it does very little or nothing. Very little in half the cases, and nothing in the other half.

    This shocking article appeared in BMJ, no less: http://www.bmj.com/content/348/bmj.g3253

    Considering this ^, it’s quite plausible that a sham procedure (cut and stitch) would be just as effective as the real operation for both TKR and THR.
    A sham procedure wouldn’t eliminate crepitus, but symtoms such as pain and stiffness should be highly amenable to expectation effects.

    For me it boils down to one thing – what degree of nociceptive firing is happening in the arthritic joint? Does anyone know the answer to this question? If it’s very high, then we can assume surgery is appropriate. If it’s not that high, conservative treatment such as suggestion might be better.

    Reply
  3. fysiomokum

    @EG for how long will such a sham-surgery be similar effective as a real operation for TKR and TH? I can only see a 12 mth follow up in your reference was done for gastro ent. placebo study.

    I’ve seen the TH surgery live done on a patient (long ago, ’89) the patient is side lying, at one point the surgeon needs to dislocate the femoral joint by internal rotation of 90 degrees! (ouch) – the artificial socket used back then was placed with a 60cm Torque wrench I remember that surgeon putting his bodyweight in to the torque wrench.
    I saw that patient the next day, he reported no pain!

    I had knee surgery myself (tibiaplateau#) they use epidural paincontrol w marcain 48h post surg. which basicely numbs everything from the pelvis down below. Mine epidural analgesics system malfunctioned within 24h, what I felt was my sensation coming back in my legs plus a wave of excruciating pain in my knee (say 200 on a scale of 0-100), morphine helped to take the extreme part of the pain away but sure not all.

    Reply
    • EG Physio

      — EG for how long will such a sham-surgery be similar effective as a real operation for TKR and TH? I can only see a 12 mth follow up in your reference was done for gastro ent. placebo study.

      I’d guess as long as the script is maintained as ‘truth’ in the patient’s subconscious.

      The quoted reference is a systematic review of all surgeries that have been compared to placebo, and it doesn’t include THR/TKR. It doesn’t include TKR/THR because no one has ever studied them. I’m just saying surgery *taken as a whole* has almost no evidence to support it currently.

      There’s just far too many inconsistencies to think that what’s happening with TKR/THR is due to the altered mechanics.

      Reply
      • fysiomokum

        When we look at the “painfree” population and OA knees there is this nicely described observation:

        “As expected, an increasing percentage of participants reported knee pain when the severity of osteoarthritis seen on x-rays increased, but still 25% of the participants with the most severe grades of osteoarthritis did not report pain in their knees.”
        BiM-2013: http://www.bodyinmind.org/factors-for-knee-pain/

        Their nervous systems don’t seem to be bothered that much by severe osteoarthritis.

        Reply
  4. betsancorkhill

    Thanks for another really great post giving me lots to think about. I think pre-op mental and physical preparation is so important and this isn’t recognised.

    A friend’s mother had a TKR a few weeks ago with no pre-op preparation and little post op. Having been on the waiting list for many months and not moved much due to pain during that time, she went into the operation at her weakest, both mentally and physically. Post op her knee was put in a passive motion machine and she found this rather scary. She felt out of control. She was then discharged with a few basic quads exercises and told to ‘get on with life’. Job done, box ticked, patient discharged quickly with new knee. Given this approach I don’t think it’s at all surprising that we see so much post operative pain requiring ongoing medical input, resources and social care.

    Why is it that the powers that be can’t see that they will SAVE money by doing it right the first time around?

    Reply
  5. EG Physio

    There’s another thing that really perplexes me about the high success rate of TKR/THR. And if someone could answer this, I’d be very pleased.

    Let’s say the pain is due to hip joint nociception. And let’s say the nociception is caused by bone-on-bone grinding, which in turn causes depolarization of the femoral, obturator, sup gluteal and sciatic sensory branches.

    Why doesn’t radiofrequency ablation of the relevant sensory nerves work very well?

    http://www.ncbi.nlm.nih.gov/pubmed/17986165

    Only a 50% improvement AND this wasn’t even placebo controlled! The whole thing could be explained by expectation effects.

    I have a strong feeling that the high success rate of surgery is expectation-mediated. It’s the only way to make sense of all of this.

    Reply
  6. davidbutler0noi

    John,
    Thanks for bringing up the issue of sex in your discussion. Rocking your pelvis around and having a bit of fun, safe in the knowledge your joints wont squeak must be one of the best things for the hip structures and their representation in the brain. I hope all health care providers are talking about it in relation to THRs.

    Thanks again

    David

    Reply
  7. Blanaid@fiorilass

    Dear John
    Thanks for such an excellent account of your experience around your new hip replacement. Your recovery is astounding but maybe not surprising considering how you approached your knee replacements!

    The account of your experience was greatly on my mind as I had surgery for a fracture recently. And so I recalled your use of mindfulness and visualization techniques, to the use of Graded Motor Imagery before and after, your belief that pain and swelling would be expected and normal, but not a sign of something more dangerous and your immediate ownership of your new knees.
    I thought of you and how you were able to “run up stairs like a five year old” as it was described and I thought “I’ll have me some of that! ”. It was powerful stuff.

    In particular, I recall you ” not waiting around for someone to push on your knees to regain your range of motion”. You didn’t expect someone to move you and were in control of your own movement from the very start. It had a powerful influence on how I viewed my own rehab. I think it is fair to say you have single handedly given us all a “template for recovery” which is really empowering.

    And so, from me to you, this is a small thanks.

    Best Wishes

    Blánaid

    Reply
  8. Jonathan Dearness

    Thank you John for your interesting insights.

    I have long believed that the “deliverables” that seem to be important to the orthopaedic team pre TKR discharge (eg 90 degrees flexion, no quadricep lag etc) are absolutely the wrong indicators of success. The attempt to reach these milestones, in the shortest possible time, often involves much cajoling, anxiety, fear, …..dare I say “bullying “, and pain. The gaining of these milestones bears little predictive value of long term satisfaction anyway.

    I had a discussion with some orthopaedic surgeons at my hospital the other day and when asked “how much physiotherapy do these people need?”, my answer was “enough knowledge to feel safe, and as free of anxiety and fear about future problems as possible”. The therapeutic interactions should be calm, and in the present moment. The use of mindfulness, and visualisation as you have described so well needs to be promoted. The historical dependence on anthropometric measurements needs to be relinquished.

    Reply

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