A Fitness Forward Approach to Managing Extremities Post-Operatively

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses various approaches to promote system-wide healing. One key aspect highlighted is the importance of education in the healing process. Lindsey emphasizes the need to educate patients about their condition and what to expect during their recovery journey. This includes providing information about tissue healing timeframes and milestones for progress. By equipping patients with this knowledge, healthcare professionals can help them understand their recovery process and make informed decisions.

Mindfulness is another approach mentioned in promoting system-wide healing. Lindsey suggests that practicing mindfulness techniques can help reduce stress and promote a calm mind. This can be achieved through activities such as breathing exercises, journaling, or spending time outdoors. By incorporating mindfulness practices into their daily routine, patients can support their overall healing process.

Exercise is highlighted as a crucial component of system-wide healing. Lindsey emphasizes that exercise should not be limited to traditional rehabilitation exercises but should also include activities like walking programs. For instance, in the case of total knee surgery, she suggests starting with a 10-minute daily walking routine and gradually increasing it to reach the recommended 30 minutes per day. Engaging in regular physical activity can improve overall fitness and support the healing process.

Diet is also mentioned as a factor that can promote healing, especially after a trauma such as surgery. Lindsey emphasizes the importance of nutrition in supporting tissue healing. Specific dietary recommendations may vary depending on the type of surgery and individual patient needs. However, healthcare professionals are encouraged to promote a healing-focused diet that provides the necessary nutrients for recovery.

Lastly, sleep is highlighted as a crucial element in promoting system-wide healing. Lindsey acknowledges that getting enough sleep can be challenging during the early stages of healing. However, they suggest providing patients with sleep hygiene tips, such as turning off electronic devices before bed or maintaining a cooler room temperature. By facilitating good quality sleep, patients can support their body's healing processes.

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

LINDSEY HUGHEYGood morning, PT on ICE daily show. How is it going? It is clinical Tuesday. I am Dr. Lindsay Hughey from Extremity Management. I led that along with Dr. Cody Gingrich, Dr. Mark Gallant, and Dr. Eric Chaconas. So happy to be with you all on a clinical Tuesday. It's been a little while. Today I'm gonna talk with you about fitness forward post-op considerations for extremity management. It's a topic that often gets asked about on our weekends and our weekends don't actually have the bandwidth to hold those questions. So I'm gonna start sharing on PT on ice a little bit more here. So I'm excited to talk with you about that. But before I do, I want to share some upcoming courses that Mark, Cody, and I have because there are only a couple more opportunities left to catch us this year. And for those courses, we are getting close to 30 for each. And so spots will run out. So if you're on the fence, consider purchasing that in the next couple of weeks. So Fremont, California, Cody will be there on December 2nd and 3rd. And then the final opportunity this year is at CrossFit Endure in Fort Collins, Colorado, on December 9th and 10th. And that one's going to be a blast and numbers are growing. So please sign up now. If you miss those two opportunities just because family stuff's going on, know that we have offerings early in January as well. So Mark in Richmond, Virginia, on January 13th, and 14th, that same weekend, we're also offering a course with me in Louisiana. So please check out our calendar. We hope to see you on the road soon.

A FITNESS-FORWARD APPROACH TO POST-OP EXTREMITY CARE So today's topic at hand, we're going to dive into what a fitness-forward approach looks like when we are managing extremities post-operatively. So I want to first just talk about the framework generally, and then use an example. And the example today we'll talk about is total knee replacement. But there are five underlying pillars that I see that are required if we really want to have an all-inclusive approach that is fitness forward for these folks. So number one, we have to be really familiar with tissue healing timeframes of that condition and what to expect and not expect for that patient along their healing journey. So we have to be intimately acquainted with what's normal and what's not, and then be willing to educate the patient about that. So that second pillar is really education. So letting the patient know in whatever surgery they have, whether upper or lower quarter, what's really gonna facilitate healing? What are the expectations for recovery in regards to milestones that they need to hit by certain times and what milestones allow them to progress? There are certain timelines that we can't violate and range of motion precautions based on that specific surgeon. So really make sure we educate the patient and they are fully aware of those precautions. As Zach Morgan said in one of his podcasts recently, we have to catastrophize rest. I'm really letting someone know that rest will never be the thing here post-operatively. Yes, we might have to rest that directed limb, at times, but our body needs movement. It needs blood flow. And so really getting that message early that just because you just have surgery doesn't mean you'll just be sitting and laying around. We actually need to move to promote blood flow and healing to that extremity. Number third pillar is the protocol. Really being intimately aware of whatever protocol the surgeon gives knowing the timelines and actually reviewing them with your patient. Not all surgeons will have a protocol, right? Every surgeon's a little different, but find an evidence-based one based on that surgery and compare a couple of them if the surgeon isn't giving you one. It is really important to kind of sit down with the patient and briefly review that so they really understand, again, what's normal and what's not, knowing what safety precautions are on board from a range of motion and active range of motion versus passive range of motion perspective, and then again, those milestones. Pillar four, system healing. How do we promote system-wide healing? Well, I already mentioned a little bit about our education, about how we're going to catastrophize rest, right? We are going to keep our humans moving, but here's where meds will come in again. And if you've heard me on the podcast, you know, or even seeing my reels, you know, meds is something I'm really passionate about. Mindfulness, exercise, diet, and sleep. And really unpacking what each one of those is for your patient, right? So mindfulness, something that kind of soothes their stress and mind or soothes their soul, helping that connect them with that, exercise, keeping that human moving in whatever way possible, diet, promoting nutrition that promotes healing, especially after a trauma, even though it's a controlled trauma, surgery is traumatic on all of our tissues. So make sure the diet matches that, and I'll unpack some of those things that promote healing as we talk about our total knee example. And then sleep, really helping facilitate ways to help a good deep sleep, that seven to nine hours, and it's so hard in those early healing stages, but giving the tips that you think will help. And it could be as small as turning your phone off an hour before bed, right? Or keep the room a little bit cooler, around like 65 degrees to help them sleep, just giving them those sleep hygiene tips. more on that as we talk about the total knee example. And then the final pillar when we're thinking about fitness forward postoperative care is capacity rebuilding. And what I mean by that is considering all tissues involved in the surgery. So think muscle, think tendon, Think ligament if that's on board. Think skin integrity, right? Because there's an incision on board. And think bone. All of these are challenged. Their capacity is challenged because there is a period where there needs to be some precautions and rest on board. And there needs to then be a period where we gradually build up that capacity as it's going down. And it is our job to prevent loss of capacity as much as possible, and then also build it up as efficiently and safely as we can. And so there are three subsets in this capacity rebuilding phase. So consider when we're thinking about like the muscle, intend and think working locally, but then also think globally right. We don't want to be just so focused if it's a shoulder surgery just on the shoulder right. We also want to be thinking about scapulothoracic muscles. So local and global considerations are key. The second subset is nervous system offense. I think unless someone complains of numbness, tingling, and vague pain sensations, we kind of ignore the nervous system. But consider the nervous system is extensive, and our muscles, ligaments, bones, and tendons are all mechanical interfaces of the nervous system. So we can use the nervous system to promote intraneural healing and blood flow offensively. So consider using your nerve glides early more for tissue healing blood flow and intraneural nutrition. So thinking about it offensively prevention. In addition, consider central sensitization prevention, right? Again, this is a controlled trauma. And we know that folks who have surgeries or injuries are more predisposed to getting injured again. So consider that things like two-point discrimination training, laterality training, and pain pressure threshold are something we should both check on and possibly train if we see impairment side to side. And I'll tell you, in those initial early stages, that four to six weeks, there is definite nociceptive pain damage on board, but consider as we get towards the end, halfway through to the end of our care, we have to make sure central sensitization hasn't occurred in those tissues or become widespread. So check and then train if necessary. And then finally, the third subset of capacity rebuilding is functional pattern training. So consider we want healthy full body patterns. And what I mean by that is initially thinking of getting someone independent in their ADLs and IADL functions. Initially, they might need some assistance, but then eventually we want to normalize those patterns so they don't need any kind of assistance, whether that be a brace or an assistive device. And then we want to prepare humans not just for daily living, normal daily living, but think of job and sports demands. ultimately functional patterns will train those good functional patterns without assistance but then think about preparing for the unknown as well because things in life and sports will happen right maybe our older adult after total knee prepare for falls right think about our person after a meniscal repair like pray prepare for unstable landing. So that's what I mean when I say prepare for the unknown, right? Prepare for real life, which we'll do in a multi-segmental compound way. So to summarize, The five things. Tissue healing time frames. Two, educate your patients. Three, know the protocol and review it with your patient. Fourth, give a meds education for system-wide healing. And then five, think about how you're going to build up capacity in muscle, tendon, ligament, bone, nervous system, and then full body capacity. I wanna briefly take you through a total knee example, how we'll apply these five pillars, just so you can consider how you can apply this really to any post-operative condition. So let's think about someone with a total knee replacement, uncomplicated.

TISSUE HEALING TIME FRAMES So tissue healing timeframes, considering just the timeline of care initially, it's gonna be anywhere from four to 12 weeks. And we're really usually seeing them right for those two to three months. letting the patient know, that that's a realistic timeframe. And that there are multiple things on board, right? We have an incision to heal, a muscle to heal, and then bone. And so that four to 12-week timeframe really encompasses that and lets that human know that this is just not a quick rehab process.

POST-OP EDUCATION In regards to our education for someone with a total knee replacement, considering our first education strategies really need to be about signs of infection, right? And anybody postoperatively, this needs to be on board, but specific to this total knee replacement, right? If there is red, hot, and warm redness that is spreading outside of that incision. Here's where we make that circle around, we see that redness, and if it spreads outside that, that becomes an emergent thing that they need immediate medical assistance for. Consider letting them know the systemic temperature. If they're running a fever greater than 101 Fahrenheit, they need to, again, get to their doctor quickly. These are things we don't wanna mess with when we think about infection associated with the prosthesis. If there are dramatic increases in pain that are debilitating, another coinciding sign of infection. So that needs to be a part of our initial early stages of education. And then obviously we're educating about our HEP and its importance, but then we need to get into some of that nitty gritty of what facilitates healing. And I can't keep echoing Zach Morgan enough that we need to catastrophize rest, that letting that patient know that they shouldn't be sitting or laying around more than 30 to 60 minutes at a time. They need to keep moving so that systemic healing can happen. Giving them specific movement HEP parameters about exercise, and we'll talk more about the specifics on this in the med section for holistic wellness, but walking, a walking program, or cardiovascular program is crucial with someone with total knee replacement because we know of the underlying metabolic disease that coincides those. that are getting a total knee replacement. And then again, in our education bucket, expectations for recovery, which includes the protocol, and then just specific functional milestones.

POST-OP PROTOCOLS That third pillar is protocol. When we think about our total knee replacement, there aren't the very hard and fast range of motion precautions we would have in like a meniscal repair. But there are some must-have range of motion milestones achieved, like in that first year to two weeks, things like there should be independent mobility and getting in and out of the home. That should be all independent or modified independent, right, where they're using an assistive device. In that two to six-week mark, they should be at zero degrees of knee extension, right, to promote that terminal knee extension in gait. Anywhere from zero to about 105 degrees of flexion is that goal in the first two to six weeks. around the five to eight-week mark, we should be progressing past 115 degrees of knee flexion. So using these as buoys and goals is something that we not only want to have in our mind but also help encourage the patient that these are like milestones we want to achieve to keep them progressing. And then when we're past that eight-week mark, we should really be close to within normal limits for range of motion. Now we know not every case goes perfectly like this, but these are overall goals. And by the end of our time in therapy, so think that 12-week mark and this is where you can really set up the patient, here's where we're headed, is a normal step through gait pattern, right? That doesn't require an assistive device ideally. Reciprocal stair climbing, step over step, unrestricted standing, and walking to complete life tasks. If this is an athlete, getting them back to their athletic demand because we do have some of our total knees are in fact, athletes. So don't hold them back if they are, but consider them for our everyday human that just wants to get back. Let's think about Betty getting back to her, taking care of her grandkids, and gardening. We need to make sure that she can get on and off the floor, that she can kneel on that prosthetic, and feel confident in that to get up and off the floor for her grandkids. So consider those timelines. when we think about system-wide healing for the person with a total knee. And this part also applies to anyone who's had a post-op or has had an operative condition.

TAKE YOUR MEDS (MINDFULNESS, EXERCISE, DIET, AND SLEEP) Mindfulness, I already mentioned, right? Some kind of stress relieving strategy, whether it's breathing, journaling, or maybe it's just sitting or walking outside, but giving them something that kind of soothes the soul and the brain. Exercise. This is not just the HEP, right, working on specific impairments. It's not just about quad sets and straight leg raises. This is actually working through a walking program for someone with a total knee. You know, in the beginning stages, it might just be in phase one, working on a 10-minute walking daily. But then we want to eke our way to that 30-minute mark, right? Because we want to meet that minimum of 150 minutes a week of daily activity. Again, think about underlying metabolic disease. The person with a total knee replacement has to build up to this to help fight systemic implications. And so whether that is, ideally it is walking, getting their walking tolerance up to that, but it could also be biking. Think cycling and or swimming. Nutrition. So when we think about diet, that D in meds, we're thinking about nutrition that promotes healing. Make sure they're eating enough protein to heal that incision and help heal the trauma associated with the surgery. They're getting hydrated enough, half their body weight in ounces. that they're eating foods rich in collagen. Think bone broth, sardines, and organ meats, because collagen has been associated with improving healing. Things that are vitamin C rich. Think of citrus fruits like oranges which are cruciferous. Veggies like broccoli Brussels sprouts and tomatoes are another good source of thinking about vitamin C. Bromelain, eat pineapples. This helps reduce pain and swelling. Assuming this is okay with their doctor and nutritionist and their pharmacist, right, not interacting with any meds, all of these natural foods will help boost healing. So just giving that general knowledge, can be really helpful in the healing process. And then I already mentioned sleep, the importance of seven to nine, hours of sleep, giving sleep hygiene. And you can see past podcasts that talk about sleep hygiene tips, or even just message me and I'll send you some. But in the person with total knee, it's not just about how to get them to sleep better, but it's giving them some education like, don't put a pillow under your knee so your knee is flexed all night. And then you're fighting to walk into that terminal knee extension we've been fighting for with the quad set multiple times a day. If you're going to put a pillow under the leg, make sure that the knee is straight, right? Think about maybe talking to them about a wedge pillow so that they're elevating that limb above the heart to help with the swelling that is ongoing in that total knee replacement, but that doesn't put that knee in a flexed position. So when we're thinking about sleep hygiene for the person with total knee, it matters how you sleep, those positions of rest. and don't fall asleep with the ice machine on. This is asking for ongoing stiffness. And if it's cold enough, possibly even does some damage to the local skin tissue. So we don't want that. So, your education on sleep is a little bit different from that person with total me.

REBUILDING TISSUE CAPACITY And then finally, because I'm running out of time, and this is a topic that is rich and I don't want to take any more, but capacity rebuilding after this last point. So think about, the muscle, tendon, bone, and nervous system. So when we think local, think about skin integrity and prescribing scar massage as soon as that incision is healed, really working on scar massage, think working along as a T and an X, and then specifically focusing on that distal one-third of the incision, it's going to be really paramount in care and getting that knee moving. For local exercise or local muscle, we're thinking of exercising the quads and hamstrings, right? For global, we're thinking above and below the knee. Think about working the glutes, glute max, glute med, but also your hip flexors and to work on your stairs, and then think below also your plantar flexors. For stair climbing and think ankle mobility for squats, When we think about nervous system offense, this is one where I think it's an untapped source, but for that intraneural healing and blood flow, think about using sciatic nerve glides for all that posterior tissue tightness and or those folks that actually have complaints, right, of pain going down the leg. Often it's a secondary result of just an antalgic gait pattern, but get them doing that early so that doesn't become a problem. Even some of our folks have some femoral nerve or saphenous issues. So think about doing some femoral nerve gliding if there are medial and lower leg issues, just that on-off pumping. And then in regards to preventing central sensitization, just consider checking and screening our two-point discrimination, our pain pressure threshold, and our laterality training as we get further out in our rehab and closer to discharge to make sure that this isn't impaired. And if it is, then we train it. And then finally our functional pattern retraining for someone with a total knee. We in the early stages will teach them in a modified way to be independent in their ADLs and IEDLs. But then we wean off of that, right? We want to normalize their gait pattern. Think we go rolling walker to cane to independent ambulation. Even in our sit-to-stands, initially, we'll allow that kick out, right, when someone's going to sit down, but eventually, we want them to use that knee flexion. So we'll have them keep that leg in place and no longer kick out that leg. So consider a functional pattern changes throughout the healing process, but eventually, no matter what, we build up. squat pattern, deadlifts, we prepare for falls by fall training and we prepare for that human to kneel as soon as that incision is healed and they feel comfortable. This is how we train in a multi-segmental way for life after total knee I have usurped my time on the PTL Night Show 21 minutes in. So this is just one small example of someone with a post-op extremity condition and how you can approach it in a fitness-forward way using the five-pillar framework. No, in a total knee, there are minimal precautions, but there are a little bit more precautions on board in other conditions. I appreciate how you can apply this in both the upper and lower quarters. Join me in a month, the day after Christmas actually, to talk about post-op incision management. I appreciate all your time to listen today about a fitness-forward approach to post-op care. Happy Clinical Tuesday, folks!

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