Perceived risks and patient concerns after a knee replacement

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses the importance of working with patients to dispel negatives beliefs & fear concerning movement aggravating symptoms. Zac describes different strategies to discuss with patients how not moving after surgery or while in pain is probably the riskiest decision. 

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

00:00 - ZAC MORGAN

Good morning PT on Ice Daily Show crew. I'm Zac Morgan, so I'm lead faculty with the spine division. I teach lumbar and cervical spine management, so you can find me on the road doing those things. Shout out to that crew in Hartford, Connecticut or Waterford, Connecticut this last week. We had a good time learning about cervical spine over there in Waterford. Few more courses on that note coming up this year that if you're trying to jump into either cervical or lumbar, just wanted to point you in the direction of. So November 11th and 12th, we'll be back in that Northeast region up in Bridgewater, Massachusetts for cervical spine. December 2nd and 3rd, Hendersonville, Tennessee for cervical spine. And then if neither one of those work for you, the next chance will be at the turn of the year on February 3rd and 4th over in Wichita, Kansas. If you're looking for lumbar spine management, we've got three different courses this year that are all still have tickets available. Frederick, Maryland, that's next week or this upcoming weekend, October 21st and 22nd. Then we've got November 4th and 5th. That'll be over in Fort Worth, Texas. And then lastly, Charlotte, North Carolina on December 2nd and 3rd. So still several Good offerings if you're looking for cervical or lumbar spine management. We've already got quite a few booked for next year as well, so if this year the calendar doesn't work out or if the Con Ed budget resets at the beginning of the year, Take a look at the 2024 course offerings as well and more to book there. 01:36 - CATASTROPHIZING REST So team, this morning I wanted to talk to you all a little bit about rest and why I think we need to catastrophize rest. I think we need to make a bigger deal out of it when our clients come in and we find out that they've been resting. So let me talk a little bit about this. I've been chewing on this idea for a while and I think it's important for us to sort of understand that when someone's in pain, their risk meter is broken. Like they don't have the ability to conceptualize what's actually risky for them often when they're in pain. And so let me unpack what I mean with maybe a clinical scenario that we're all really familiar with. Let's think about something like a knee replacement. I think most of us in our career will interact with patients who have had a knee replacement. Usually we have interacted with those people on the days right after they have had a knee replacement or maybe you're the one that's getting them out of the bed in the hospital and you're the first person that's getting that person moving. I think we understand the risks to this person pretty well, and as a profession, we respond to them pretty well. We understand what this person's actual risk is when it comes to the knee replacement, and their risk would be being too sedentary or resting too much. And what would come alongside of that risk would be a lot of problems that we'll cover in a bit. You think about what that person's concerned about when you talk to that person in the subjective exam on day one, or maybe you just went into their hospital room and you're talking to them. That person's usually concerned about things that are unwarranted. They're worried that their knee is gonna pop out when you start to flex it. The first time you have that person do active range of motion, that person's like, oh my gosh, is my knee gonna fly out? Is the implement actually gonna pop out? They're worried about things like that, but we as PTs, we know that's not very common. We tend to mobilize knees really early and get them moving really, really rapidly and get as much range of motion as possible as quickly as possible in something like a knee replacement because we know that it's crucial that that happens at short term. So a large part of our job early on in managing this person who has just had a knee replacement is convincing them that their risk meter is off. Again, they're afraid to move. They walked through the door that day with a lot of blood in their amygdala. They were very concerned. They were worried, what if something's going wrong? I didn't know it was going to hurt this bad. I didn't think it was going to be quite like this. And they have typically not been moving as a response to all that pain. 03:22 - CONVINCING PATIENTS TO MOVE And our job is to help them understand that, hey, if you don't move, that's where the risk lives. The risk lives in being sedentary after a knee replacement. Like what's actually risky is if we don't move, the blood will pool, right? And we will wind up with things like a blood clot. Very risky. If a blood clot ends up dislodging and we end up with a pulmonary embolism, that's life-threatening. So that's real risk. That's something that we have to help those people understand is like, hey, if you're too still, we could wind up with something like a blood clot. And maybe we don't fear-monger that to patients, but we do help them understand that risk. You think about some of the other risks that that person has if they don't get moving. What about long-term mobility? If a knee replacement patient does not get their knee moving, you think about what that person's long-term mobility is gonna look like, and it's gonna be quite poor. That first 12 weeks after knee replacement is the most important time for us to restore full extension and get as close to full flexion as we can. We're really trying hard to push range of motion early because we know that person's long-term risk is having a stiff knee. and then not being able to participate in some of their ADLs because of the immobility in their knee. We get the risk so we help unfold that to the people in front of us. I mean the last big ones that happen if someone rests are things like atrophy or loss of cardiovascular endurance and we know this happens very very rapidly. when someone's on bed rest, when someone's immobilized, when somebody's truly sedentary or even sedated, things like that. We know the body responds and we see wasting of all those systems. The same thing's happening if someone doesn't move when they've had knee replacement. maybe not as rapidly as true rest, but we know that they're losing muscle mass, we know their muscle girth is going down, we know their endurance is getting worse. All of these things are truly risky for that person. And for that reason, I think we as PTs do a really good job of helping that person understand, hey, I know it hurts, but the risk of you moving through pain is much less than the risk of you not moving through pain. So I need you to move. And I think we do a really good job with patients like knee replacement patients or patients with a knee replacement. I think we do a really good job with those folks, getting them moving, even though it hurts, getting them back to their ADLs, getting them progressively loaded back to where they're out of sort of disability. I want to shift gears now. And I want to talk a little bit more about my expertise area, which is cervical spine and lumbar spine. So patients with neck pain and patients with back pain. That's typically who I'm seeing the most of in the clinic these days. And I think our response to these folks is a bit different than it is with the knee replacement patients, which is sort of understandable, because with a knee replacement, you understand exactly what happened to that person, where with back pain and neck pain, we never know what the tissue driving their symptom is. 06:57 - FEAR & OUTCOMES WITH BACK PAIN But I think we often respond with fear, and I think that influences the person's outcome. So let me unpack what I mean. So when someone acutely strains their back, they do something, they were lifting their kid and something happens and now their back is really strained and they're in high, high levels of pain and usually high levels of disability as well. Like a lot of patients will tell me, Zach, I can't even tie my shoes. I have to have my wife help me tie my shoes. I can't get my pants on. I can't get on and off the toilet. The activities of daily living are really influenced by these high pain levels. And a lot of these people, when you start to talk to them, they're terrified to move. Especially a forward bending, but really just to A lot of people in general with acute back pain, they're so scared to move their back around. And they're afraid that what will happen if they move their back around, is that they'll worsen their scenario. They're concerned that if they move too much, and maybe some of this is valid, but if they move too much, they'll worsen whatever's wrong with their back, and then they'll have long-term problems. But team, as you're hearing that unfold, you and I both know that's not the case, right? Like it's actually the people who choose not to move who usually wind up with worse recurrence of their back pain. It's why, I mean, you look at the Olivera study in 2018, where they compared all the lumbar clinical practice guidelines around the globe that they could get their hands on. And there's really only two things, all CPGs, not profession specific, um, not region specific, just all the CPGs that they looked at in that study, they agreed on two things. One of them, don't image. The second one, get moving, right? Don't rest, some sort of exercise. We know people with back pain need to get moving. It is clear, no one argues about that anymore. There's no studies, no big studies that have looked into, hey, rest is actually the successful recipe for back pain. It's not that. We gotta get them moving. But I think sometimes we let our fear of allowing that person to move hold them back. But we need to conceptualize those risk factors. Like you think about what it was like for your knee replacement patient. Maybe we don't have the same concern of like a blood clot or an infection, but think about this person's other risks. 06:57 - THE IMPORTANCE OF MOVEMENT Like, what about long-term mobility? If someone doesn't restore their ability to forward bend, they often end up with a loss of long-term lumbar flexion. And how does that usually wind up? Maybe sometimes they're fine and they're asymptomatic throughout the rest of their life, but often when I see recurrent back pain patients, They have had episodes throughout life and they've chosen to avoid a certain range of motion and part of our job is to do some graded exposure back to that to help them conceptualize the risk. To help them realize actually being still is where the risk is. We've got to get moving. You think about atrophy. You think about what happens to that person's muscular system. If they have severe back pain and they're not doing the things that they normally do, perhaps they're laying in bed a little bit more, sometimes they're laying on the couch a bit more, a lot of times their spouse is helping them out, their partner is helping them out with a lot of their ADLs. Team, when people have acute back pain, they often get very still because their fear level is really high, and part of our job is to help them understand that where their head is at, what they're concerned about, is actually much less risky than being still right now. Being still is where the risk lies. If we don't get back to movement, you're going to lose that long-term mobility. You're going to lose a lot of your muscular system. You're going to end up losing quite a bit of your cardiovascular endurance. That's where the risk lies. Because what do we all know about people who tend to lose muscle mass, who tend to lose cardiovascular endurance? Most of those people will struggle to get that back. And I think the longer they live, the more challenging that climb back to fitness is going to be. So our older adult clients are definitely in this boat. We've got to keep these people moving. We've got to get them afraid of resting. That's where the fear should be because what happens when you rest is the long-term stuff. That's what causes recurrent back pain. If a person hurts their back and they're now afraid to move in that range of motion and they don't restore capacity, whether that's cardiovascular capacity or the actual strength of the tissues because of fear, now that area is more fragile. It's more susceptible to injury. They're usually careful with that area and being careful with that area often is not a solution for getting rid of a recurrent back pain. As a matter of fact, we want to move more towards things like graded exposure, graded exercise, building that engine, building the tissues, how robust that underlying tissue is. That comes with movement. It doesn't come with rest. So team, I think just putting this whole thing into perspective, what I want to get across this morning is that when someone comes in to see you in pain, their brain is not in the right decision making area to understand risk. Their amygdala has all the blood in it. They're really concerned. they don't know if they're going to be okay. It is our job to use our prefrontal cortex because we can use that in that state because we're not anxious because we see this all the time. We use our prefrontal cortex to say, you know what, actually we need to develop a plan that gets you back to X, Y, and Z. And that's what we do with rehab. And that's how we try to bring down that recurrence, is we avoid all these catastrophes that happen when people sort of follow their natural instinct, which is to rest. So that's all I've got for you this morning. I want us all catastrophizing rest a lot more on our patients, helping them understand that that is not necessarily the safe choice. A lot of times people's risk meter is broken there and it's actually the unsafe choice. So let's catastrophize rest, get out there this Tuesday team, meet us on the road if you're looking for anything. Please feel free if you want to have a big conversation here, jot it into the thread and I'll be on here all day answering any questions. Thanks team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. 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