By DR CATHERINE L WHITEUpdated: MARCH 27, 2018 13:25
Recently, an important “statistic” has come to light for me, which frankly astonished me when it was first revealed. That is – many Orthopedic Surgeons say that when they “prescribe Physical Therapy” for their post-operative patients, most patients actually do not do their exercises at home. Oh, the patients put a good front when they go into their sessions with their Physical Therapist. But it’s pretty obvious when you watch them attempting to do some newly introduced activity which the therapist added that the patients are not familiar with what they were taught to do.In residency, a highly respected Orthopedist I worked with once asked me, “Where is the best place to send patients to physical therapy?”Such a question baffled me, and I answered, “Wherever they’ll do the therapy they need?” He acknowledged that answer was close, but it wasn’t the answer he was seeking.He replied, “It is the closest facility to their home. They won’t go to Physical Therapy if it isn’t convenient.”Usually, Physical Therapy begins after surgery and commences for weeks, with multiple sessions per week. The Physical Therapist also will usually prescribe exercises done three times daily. One facility where I worked insisted that the only prudent post-operative orthopedic care after joint replacement (especially joints below the waist) was an inpatient-unit specializing in joint rehabilitation. It was felt that the patients’ entire day (which coincided with the therapists’ 8-hour daily shifts) would be consumed with repeating the series of exercises necessary to regain function of the joint. Plus the patients needed proper nutrition and rest to recover well from the arduous procedures that they had recently undergone. In these specialty hospitals, joint replacement patients received the supervision and support they needed.In retrospect, while I think this is a great idea, it can be an enormous health care expense. Some insurance policies and coverage plans also limit the amount of time someone can stay at these specialty care facilities. While cutting health care expenses may sound like a great idea, a doctor has to take into consideration whether the best outcomes would occur if the patients went to the specialty units or if they can effectively perform their recovery activities at home. Usually, the best outcomes are associated with admission to a transitional specialized care unit before sending the patients home.Of course, there are always the families who insist that they can ensure the rehabilitation is done as instructed. Especially if they have a family member who is a Physical Trainer at a fitness club.And, of course, there’s always the person who “fails” the transitional specialty care units and they never learn to use their joints effectively nor recover full function of the affected area. In one such case, I saw that the specialty care unit discharged a knee-replacement patient early because she just wasn’t progressing as she should.What was her excuse for not obeying the strict regimen taught to her? She wanted everybody at the unit to like her. And she felt like the staff would be talking behind her back about how the “old lady in room XXX was so slow”. I’ve tried rationalizing with such people, saying that the Physical Therapy staff at these specialty rehabilitation facilities wanted to see all patients use their new joints successfully, and that was their job – to help patients recover as much functionality as possible. But such pleas fell on deaf ears.In the case of this patient in the example, she never learned to walk properly on her new knee joint. In fact, she used her leg like a pirate would use a peg-leg, never bending her knee at all. I insisted that she go for outpatient therapy to learn how to use the joint properly but she wouldn’t go saying she was “too busy” and she was “getting along just fine”. I think she was also concerned that Medicare would not pay for additional therapy and her supplemental insurance might not cover the sessions.
To me, this was a wasted surgery at the US taxpayers’ expense (since Medicare paid for most of it). She had more pain in her leg and lower back than she would have had if she hadn’t undergone joint replacement. Later on, I discovered her knee really wasn’t as painful as she had initially said! So when people ask me what I think, I usually give the caveat that a lot of people aren’t actually having enough pain before surgery to justify undergoing the procedure and the risks involved with the surgeries.Before surgery, this same patient kept insisting she “needed” to undergo this knee surgery “because it [her knee] hurt”. The most successful joint replacement candidates are those people who suffer from such excruciating pain (most likely related to arthritis) that when they take that first step with their Physical Therapists after surgery, the excruciating pain is gone. Their knees, feet, or hips will hurt some after surgery from what they underwent, because this kind of surgery isn’t “a walk in the park” (as a lot of doctors say). It’s simply that the pain they experienced in recovery and with Physical Therapy was so much less than what they had been experiencing on a daily basis.On top of everything, this example patient nearly died in the inpatient Orthopedic ward because she developed a pulmonary embolism immediately post-operatively. This happens when arterial blood vessels in the lungs are occluded from a blood clot – much like how heart attacks are caused in the same manner. These blood clots result during surgery as the leg is firmly immobilized in order for the surgeons to do their precision work. With immobilization, the remainder of the leg isn’t getting optimal blood supply or venous blood return.Or, sometimes there are “fat embolisms” where little pieces of the bone marrow from the cut or damaged bone enter the blood stream and occlude necessary organ arterial circulation (however, this tends to happen a little more in hip replacement patients than knee replacements). The first night I was on-call in residency, I had to respond to a 80-plus-year-old hip replacement patient who was having a heart attack from a fat embolism. The expert Interventional Cardiologists at that hospital saved his life through cardiac catheterization.Another type of patient that fails inpatient Physical Therapy is the individual who (for reasons of dementia, pride, or having a sense of physical prowess in their youth which they feel they need to recover immediately) just don’t follow the instructions their Physical Therapists give them. They do unsafe maneuvers just because they “used to be able to do” certain things. In dementia patients, they “get labeled” as “showing poor and unsafe judgment” or “being incapable of following directions”. I’ve seen people like this being permanently and prematurely confined to wheel chairs with alarms where they are not allowed to stand or walk without experts’ intervention.In the past, some patients have asked me if there is any way they can recover from joint surgery without going to Physical Therapy. The answer is a simple, “No!” A friend of mine in Medical School who had Physical Therapy after a bad accident said, “It’s painful! It takes a long time to recover and it requires a big commitment to stick with it!” That may be the case but there still is no substitute for Physical Therapy.So, if any reader has been “prescribed Physical Therapy” for any reason, my advice is, “Just Do It! Do exactly what the therapists say you can do.” Life will be so much easier, believe me!